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THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 

ISAAC HAYS, M.D., 

SURGEON TO WILLS' HOSPITAL. 

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; MEMBER OF THE 
AMERICAN MEDICAL ASSOCIATION; OF THE AMERICAN PHILOSOPHICAL SOCIETY; OF THE 
ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA, 

Sec. Sec. &c. 



NEW SERIES. 




PHILADELPHIA: 
BLANCHAED & LEA. 

1852. 



69449 



EifTERED according to Act of Congress, in the year 1852, by 
BLANC HARD AND LEA, 
in the Clerk's Office of the District Court of the Eastern District of Pennsylvania. 




PHILADELPHIA : 
T. K, AND P. G. COLLIMS, PRINTERS. 



\0.^ 
513 

led. 



TO READERS AXD CORRESPONDENTS. 

Several articles in type for this Number have been excluded for want of room, 
although we have considerably exceeded our limits. 

The communications of Drs. Bowditch, Wynne, May, Cock, Burnett, IIas- 
KiNs, Troy, Bailey, Peirce, Kemp, Rauch, and Brooks are on file for publica- 
tion. 

The following works have been received : — 

Medico-Chirurgical Transactions. Published by the Royal Medical and Chi- 
rurgical Society of London. Yol. XXXVI. London, 1851. (From the Society.) 

Guy's Hospital Reports. Second series. Edited by E. L. Birkett, M. D.. 
Cantab., &c., and Alfred Poland, F. R. C. S., &c. Vol. VII. Pt. 2. London! 
1851. 

The Principles and Practice of Obstetric Medicine and Surgery, in reference 
to the Process of Parturition. Illustrated by 148 Figures. By Francis H. 
Ramsbotham, M. D,, F. R. C. P., &c. &c. The sixth American from the enlarged 
and revised London edition. Philadelphia: Blanchard & Lea,. 1851. (From 
the Publishers.) 

Elements of Physiology, including Physiological Anatomy. By Wai. B. Car- 
penter, M. D., F. R. S., &c. &c. Second American from a new and revised 
London edition, with 190 illustrations, Philadelphia: Blanchard & Lea. 1851. 
(From the Publishers.) 

Operative Surgery, based on Normal and Pathological Anatomy. By J. F. 
Malgaigne, Professor Agrege de la Faculty de Medecine de Paris, &c. &c. 
Translated from the French by Frederick Brittan, M. D., &c. &c. Illustrated 
by wood engravings from designs by AYestmacott. Philadelphia : Blanchard 
& Lea, 1851. (From the Publishers.) 

Medical Lexicon. A Dictionary of Medical Science ; containing a concise 
explanation of the various subjects and terms of Physiology, Pathology, Hy- 
giene, Therapeutics, Pharmacology, Obstetrics, Medical Jurisprudence, &c. &c. 
By Robley Dunglison, M. D. Eighth edition, revised and greatly enlarged. 
Philadelphia: Blanchard & Lea, 1851. (From the Publishers.) 

The Elements of Materia Medica and Therapevitics. By Jonathan Pereira, 
M. D., F. R. S., &c. &c. Third American edition, enlarged and improved by 
the author. Including notices of most of the Medicinal substances in use in 
the civilized world, and forming a complete encyclopedia of Materia Medica. 
Edited by Joseph Carson, M. D,, Professor of Materia Medica and Pharmacy 
in the University of Pennsylvania, Yol. I. Philadelphia: Blanchard & Lea. 
1852. (From the Publishers.) 

An Analytical Compound of the various branches of Medical Science, for 
the use and examination of Students. By John Neill, M, D., Demonstrator of 
Anatomy in the University of Pennsylvania, and Francis G. Smith, M. D., Lec- 
turer on Phys. in the Philadelphia Association for Medical Instruction. Se- 
cond edition, enlarged and improved. Philadelphia: Blanchard & Lea, 1852. 
(From the Publishers.) 

Synopsis of the Course of Lectures on Materia Medica and Pharmacy, deli- 
vered in the University of Pennsylvania, By Joseph Carson, M. D, Phila- 
deiphia: Blanchard & Lea, 1851. 



2 



TO READERS AND CORRESPONDENTS. 



The Microscopic xinatomy of the Human Body in Health and Disease. H- 
lustrated with numerous drawings in colour. By Arthur Hill Hassall, M. B., 
&c. &c. With additions to the Treatment and Plates, and an Introduction 
containing instructions in Microscopic Manipulation. By Henry Vanarsdale, 
M. D. 2 Vols. New York : Pratt, Woodford & Co., 1851. (From the Pub- 
lishers.) 

Essays on Infant Therapeutics. To which are added Observations on Ergot; 
History of the Origin of the use of Mercury in Inflammatory complaints; toge- 
ther with the Statistics of the deaths from Poisoning in New York in the years 
1841-42-43. By John B. Beck, M. D., &c. &c. Second edition, enlarged and 
revised. New York: Wm. E. Dean, 1852. (From Dr. T. R. Beck.) 

On the Healing of Wounds in Articular Cartilages, and on the Removal of 
these Structures after Amputations at the Joints, with Remarks on the Relation 
which exists between the Diseases of Cartilage and Ulceration and Inflamma- 
tion in other Textures. By P. Redfern, M, D., &c.. Lecturer on Anat. and 
Phys, and Histol. at the University and King's College, Aberdeen. (From the 
Author.) 

Observations on Chronic Hydrocephalus, acquired, sanguineous, and conge- 
nital : with an account of three cases in which the head was punctured, and 
an examination of the effects of that operation. By Francis Battersley, M. B., 
&c. &c. Edinburgh, 1850. (From the Author.) 

Observations relative to the state of the Skull and of the Brain in Congeni- 
tal Hydrocephalus, and to Idiocy and Paralysis attending it. With cases. By 
Francis Battersley, M.B., &c. &c. Edinburgh, 1851. (From the Author.) 

On the Preservation of the Health of Women at the Critical Periods of Life. 
By E. J. Tilt, M. D., &c. &c. London, 1851. (From the Author.) 

Retro-Pliaryngeal Abscess ; its Medical History and Treatment ; with a Sta- 
tistical Table of fifty-eight cases. By Charles M. Allen, M. D., Resident 
Surgeon of the New York Hospital. [Reprinted from the New York Journal 
of Medicine.] New York, 1851. (From the Author.) 

Transactions of the Medical Association of South Central New York, at the 
annual meeting held at Binghamton, June, 1851. Binghamton, 1851. (From 
Dr. George Burr.) 

Transactions of the First Annual Meeting of the Kentucky State Medical 
Society, held in the City of Frankfort, on the 1st of October, 1851. Frankfort, 
185L 

Minutes of the Proceedings of the South Carolina Medical Association, at its 
Annual Meeting, May, 1851 ; together with the Transactions of the Board of 
Counsellors and the Anniversary Oration by Dr. T. Y. Simons. With the Con- 
stitution, as revised. Charleston, 1851. 

Summary of the Transactions of the College of Physicians of Philadelphia. 
From August 5th to October 7th, 1851, inclusive. 

Southern Medical Reports ; consisting of General and Special Reports on the 
Medical Topography, Meteorology, and prevalent diseases of Louisiana, Ala- 
bama, Mississippi, North Carolina, South Carolina, Georgia, Florida, Arkansas, 
Tennessee, Texas, and California. To be published annually. Edited by E. 
D. Fenner, M.D., of New Orleans. Vol. II. 1850. New Orleans, 1851. (From 
the Editor.) 

Lectures on Materia Medica and Therapeutics, delivered in the College of 
Physicians and Surgeons of the University of the city of New York. By John 
B. Beck, M.D., late Professor of Materia Medica and Medical Jurisprudence. 
Prepared for the press by his friend, C. R. Oilman, M. D., Professor of Obste- 
trics, &c. New York: S. S. & W. Wood, 1851. (From the Publishers.) 

A System of Operative Surgery, based upon the Practice of Surgeons in the 
United States: and comprising a Bibliographical Index and Historical Record 



TO READERS AND CORRESPONDENTS. 



3 



of many of their operations, for a period of 200 years. By Henry H. Smith, 
M. D., Surgeon to St. Joseph's Hospital, &c. &c. Illustrated by numerous steel 
plates. Philadelphia: Lippincott, Grambo & Co., 1851. (From the Pub- 
lishers.) 

Lectures on Scarlet Fever. By Caspar Morris, M. D., &c. Philadelphia : 
Lindsay & Blakiston, 1851. (From the Author.) 

An Appeal to the Legislature of Alabama, for the Establishment of a State 
Hospital for Lunatics and Idiots, prepared by Order of the " Alabama State 
Medical Society.^^ Mobile, November, 1851. (From Dr. Lopez.) 

An Address delivered before the Pennsylvania Society of Dental Surgeons, 
at the Sansom Street Hall, Philadelphia, October 10th, 1851. By Elisha Town- 
send, D.D. S., &c. Philadelphia: 1852. (From the Author.) 

On the Employment of Water in Surgery. By Alphonse Augtjste Amussat, 
of Paris. Translated from the French by Frank H. Hamilton, M. D., Professor 
of Surgery in the University of BuflFalo, &c. Buffalo, 1851. (From the Author.) 

A Statistical and Critical Account of the Fractures occurring in the New 
York Hospital, during the period of twelve years elapsing between the 1st of 
January, 1839, and the 1st of April, 1851. By Frederick D. Lente, M. D., late 
Resident Surgeon. Reprinted from the New York Journal of Medicine. New 
York: 1851. (From the Author.) 

Hints to the People upon the Profession of Medicine. By "Wm. Maxwell 
Wood, M. D., Surgeon U.S.N. Buffalo: George H. Derby & Co., 1852. 
(From the Publishers.) 

Cox's Companion to the Sea Medicine Chest, and Compendium of Domestic 
Medicine, &c. &c. Revised and considerably enlarged by R. Davis, M. R. C. S. 
First American from the thirty-third London edition. New York : S. S. & W. 
Wood, 1851. (From the Publishers.) 

A Treatise on the History, Etiology, and Prophylaxis of Trismus Nascentium. 
By John M. Watson, M. D. Second edition. Nashville, 1851. 

The Sanitary Condition of New Orleans, as illustrated by its Mortuary Sta- 
tistics. By J. C. SiMONDS, M, D. (From the September No. of the Charleston 
Med. Journ.) Charleston, 1851. (From the Author.) 

The Pocket Formulary and Synopsis of the British and Foreign Pharmaco- 
poeias : comprising standard and approved Formulse for the preparations and 
compounds employed in medical practice. By Henry Bentley. First Ame- 
rican from the last London edition, corrected, improved, and enlarged. Phila- 
delphia: Lindsay & Blakiston, 1852. (From the Publishers.) 

The Physician's Visiting List, Diary, and Book of Engagements, for 1852. 
Philadelphia: Lindsay & Blakiston. (From the Publishers.) 

Eighth Report to the Legislature of Massachusetts, relative to the Registry 
and Returns of Births, Marriages, and Deaths in the Commonwealth, from May 
1st, 1848, to January 1, 1850. By Amasa Walker, Secretary of the Common- 
wealth. Boston, 1851. (From Josiah Curtis, M. D.) 

Twenty-first Annual Report of the Belfast District Asylum for the Insane of 
the Counties of Antrim and Down, and the County of the town of Carrickfer- 
gus, for the year ending 31st March, 1851. Drawn up by the Resident Physi- 
cian. Belfast, 1851. (From Dr. R. Stewart, R. P.) 

Fifteenth Annual Report of the Directors and Superintendent of the Ver- 
mont Asylum for the Insane. Sept., 1851. (From Dr. W. H. Rockwell.) 

Lecture, Introductory to the course on the Institutes of Medicine in the Uni- 
versity of Pennsylvania. By Samuel Jackson, M. D. Published by the Class. 
Philadelphia, 1851. (From the Author.) 

On the Progress of Recent Science ; A Lecture introductory to the Course of 



4 



TO READERS AND CORRESPONDENTS. 



Practice of Medicine. By J. K. Mitchell, M. D., Professor in the Jefferson 
Medical College, Delivered November 13th, 1851. Published by the Class. 

Causes of Insanity. An Address delivered before the Norfolk (Mass.) Dis- 
trict Medical Society, May 14th, 1851. By Edwakd Jarvis, M. D., of Dorches- 
ter. (From the Author.) 

Outlines of Chemistry : For the use of Students. By Wm. Gregory, M. D. 
First American from the second London edition, revised, corrected, and en- 
larged. By J. M. Saunders, M. D. H. W. Derby & Co., Cincinnati, 1851. 
(From the Publishers.) 

Researches upon the Origin, Mode of Development, and Nature of the Sper- 
matic particles among the four classes of Vertebrated Animals. By Waldo J. 
Burnett, M. D. (From the Memoirs of the American Academy of Arts and 
Sciences.) From the Author. 

The following Journals have been received in exchange : — 
Vierteljahrschrift fur die praktische Heilkunde, herausgegeben von der Me- 

dicinischen Facultat in Prag. Red. Dr. J. Halla und Dr. J. Y. Hasner. Bd. 

I. II. and III., 1851. 

The London Medical Gazette. August, October, November, 1851. 

London Journal of Medicine. September, October, November, December, 
1851. 

The Dublin Quarterly Journal of Medical Science. October, July, 1851. 

The Dublin Medical Press. September, October, November, 1851. 

The Edinburgh Medical and Surgical Journal. October, 1851. 

The British and Foreign Medico-Chirurgical Review. October, 1851. 

The Journal of Psychological Medicine and Mental Pathology. Edited by 
Forbes Winslow, M. D. October, 1851. 

Medical Times. October, November, December, 1851. 

Provincial Medical and Surgical Journal. Joint Editors, W. H. Ranking, 
M. D., and J. H. Walsh, Esq. October, November, December, 1851. 

Monthly Journal of Medical Science. Conducted by Professors Christison, 
Syme, Simpson, and Bennett, and Drs. Madagan and Robertson. November, 
1851. 

British American Medical and Physical Journal. Edited by Archibald 
Hall, M. D. October, November, December, 1851. 

The American Journal of Pharmacy. Published by authority of the Phila- 
delphia College of Pharmacy. Edited by Wm. Proctor, Jr., Professor of Phar- 
macy, &c. &c. October, 1851. 

The American Journal of Insanity. Published by the New York State Lu- 
natic Asylum, Utica. October, 1851. 

St. Louis Medical and Surgical Journal. Edited by Drs. Linton, Moore, 
McPheeters, and Johnson. October, November, December, 1851. 

The New Jersey Medical Reporter and Transactions of the New Jersey Me- 
dical Society. Edited by Joseph Parrish, M. D. October, November, Decem- 
ber, 1851. 

The Western Journal of Medicine and Surgery. Edited by L. P. Yandell, 
M. D. and T. S. Bell, M. D. September, October, November, 1851. 

The Stethoscope, and Virginia Medical Gazette. Edited by P. C. Gooch, 
M. D. October, November, December, 1851. 

The North Western Medical and Surgical Journal. Edited by John Evans, 
M. D. September, November, December, 1851. 



TO READERS AND CORRESPONDENTS. 



5 



The New Orleans Medical and Surgical Journal. Edited by A. Hester, M. D. 
September, November, 1851. 

The Western Medico-Chirurgical Journal. Edited by Drs. Sandford and 
Armor. August, September, October, 1851. 

The Boston Medical and Surgical Journal. Edited by J. C. Y. Smith. Oc- 
tober, November, December, 1851. 

The New Orleans Monthly Medical Register. Edited by A, F. Axon, M. D. 
October, November, December, 1851. 

The American Journal of Dental Science. Edited by Chapin A. Harris, 
M. D., D. D. S., and Alfred A. Blandy, M. D., D.D. S. October, 1851. 

The New York Medical Gazette and Journal of Health. Edited by D. M. 
Eeese, M. D. October, November, December, 1851. 

The New York Medical Times. Edited by J. G. Adams, M. D. October, 
November, December, 1851. 

The New Hampshire Journal of Medicine. Edited by Edward H. Parker, 
M. D. September, November, December, 1851. 

The Transylvania Medical Journal. Edited by Drs. Dudley, Bullitt, and 
Raphael. September, October, November, December, 1851. 

Nelson's Northern Lancet and American Journal of Medical Jurisprudence. 
Edited by Horace Nelson, M. D. October, November, December, 1851. 

Nashville Journal of Medicine and Surgery. Edited by Drs. E. K. Bowling 
and P. F. Eve. October, 1851. 

The Western Lancet. Edited by Dr. L. M. Lawson and George Mendenhall. 
October, November, 1851. 

The American Journal of Science and Arts. Conducted by Professor B. Sil- 
LiMAN, B. SiLLiMAN, Jr., and James D. Dana and Dr. Wolcott Gibes. Sep- 
tember, November, 1851. 

The Ohio Medical and Surgical Journal. Edited by Richard L. Howard, 
M. D. September, November, 1851. 

The New York Journal of Medicine and the Collateral Sciences. Edited by 
S. S. Purple, M. D. November, 1851. 

Southern Medical and Surgical Journal. Edited by L. A. Dugas, M. D. 
November, 1851. 

The Medical Examiner. Edited by F. G. Smith, M. D. and J. B. Biddle, 
M. D. October, November, December, 1851. 

The Charleston Medical Journal and Review. Edited by D. J. Cain, M. D. 
and F. P. Porcher, M. D. November, 1851. 

Buffalo Medical Journal. Edited by Austin Flint, M. D. October, Novem- 
ber, December, 1851. 

The Dental Times and Advertiser. Edited by Alfred A. Blandy, M. D., 
D. D. S. December, 1851. 

Nordamerikanischer Monatsbericht fur Natur-und Heilkunde. Redigirt von 
Dr. W. Keller and Dr. H. Tiedemann in Philadelphia, and Dr. Herzka in 
New York. October, November, December, 1851. 



Communications intended for publication, and Books for Review, should be sent, free 
of expense, directed to Isaac Hats, M. D., Editor of the American Journal of the Medical 
Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed as above, and 
sent (carriage paid) under cover, to John Miller, Hem-ietta Street, Covent Garden, London ; 



6 



TO READERS AND CORRESPONDENTS. 



or to John Wiley, or G. P. Putnam, New York ; or W. D. Ticknor, Boston; or M. Hector 
Bossange, Lib. qiiai Voltaire, No. 11, Paris, will reach us safely and without delay. We 
particularly request the attention of our foreign correspondents to the above, as we are 
often subjected to unnecessary expense for postage and carriage. 

All remittances of money, and letters on the business of the Journal, should be addressed 
exclusively to the publishers, Messrs. Blanchard & Lea. 

0^ The advertisement-sheet belongs to the business department of the Journal, and 
all communications for it should be made to the publishers. 



We have been requested by Dr. Donaldson to correct some errors in his interesting 
papers, which escaped his observation in reading the proofs. 

The formula for " La liqueur de Bareswil," see p. 39, No. for July, 1851, should be 
as follows: — 

R. Crystallized Carbonate of Soda ^i, ^ j ; 
Caustic Potash ^ij, 9 ij ; 
Bitartrate of Potash gj, ^ij; 
Sulphate of Copper ; 
Distilled Water Oj. TT]^. 
To be boiled and then filtered. Add in the proportion of from one-sixth to one- 
fourth, to the fluid to be tested, and boil the mixture for a few minutes over a spirit-lamp, 
or in a water-bath. 

Page 40, line 2 from top, dele "a few drops of" 

No. for October, 1851, page 357, line 33 from top, for " butyric," read bituric. 
Page 363, line 27, for " pulmonary artery," read pulmonary veins. 
lb. line 28, for "pulmonary and other veins," read pulmonary artery and the other 
veins. 



CONTENTS 



OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 
NO. XLY. NEW SEEIES. 
JANUARY, 1852. 



ORiaiNAL COMMUNICATIONS. 
MEMOIRS AND CASES. 

ART. PAGE 

I. Medical and Surgical Notes of Campaigns in the War with Mexico, 
during the years 1845, 1846, 1847, and 1848. By John B. Porter, M. D., 
Surgeon U. S. Army. - - 13 

II. Cases of Empyema, with Remarks, especially in reference to Paracen- 
tesis. By Wm. Pepper, M. D., one of the Physicians of the Pennsyl- 
vania Hospital. - - - - - - - -38 

III. Summary Report of the Hospital Department of the U. S. Frigate 
Cumberland, during a cruise to the Mediterranean, from July 19th, 
1849, to July 9th, 1851. By Edward R. Squibb, M. D., Assistant Sur- 
geon U.S.N. - - - _ - - ^ - - 54 

lY. On the Treatment of Yesico-Yaginal Fistula. By J. Marion Sims, 
M. D., of Montgomery, Ala. [With twenty-two wood-cuts.] - - 59 

Y. Remarks on Atelectasis Pulmonum, or Imperfect Expansion of the 
Lungs, and Collapse of the Lungs in Children ; with cases. By J. For- 
syth Meigs, M. D., Lecturer on Practice of Medicine in the Philadelphia 
Medical Association. - - - - - - -83 

YI. Extracts from the Records of the Boston Society for Medical Improve- 
ment. By Wm. W. Morland, M. D., Secretary. - - - - 103 

YII. On the Reproduction of Lactation. By Ariel Ballon, M. D. (Read 
before the Rhode Island Medical Society, June, 1851.) - . - 124 

YIII. On the Relations of the Medical Witness with the Law and the Law- 
yer. By Samuel Parkman, M. D., one of the Surgeons of the Massa- 
chusetts General Hospital. (Read to the Boston Society for Medical 
Observation.) 126 

IX. A Case of Ossification of the Placenta, occurring several times in the 
same Individual. By Charles Garrison, M. D., Swedesboro', New Jer- 
sey. - - - - - - - - - - 134 

X. A Case of Poisoning with Oil of Tansy — Death at the end of three 
hours and a-half — Quantity of the Drug taken about and ^iii. By 
John C. Dalton, Jr., M. D. (Read to the Boston Society for Medical 
Observation, June 2d, 1851.) - - - ^ - - - 136 

XI. Case of Puerperal Fever treated successfully with Opium in large 
Doses. By Wm. Kelly, M. D., Resident Physician to BlackwelFs Island 
Hospital, New York City. - - - - - - - 140 

XII. Cases of Delirium Tremens successfully treated by the Administra- 
tion of Chloroform. By Stephen H. Pratt, M. D., of Baltimore. - 142 



8 



CONTENTS. 



XIII. Paronychia an Epidemic. By James E. Morgan, M. D., Demon- 
strator of Anatomy in National Medical College, Washington, D. C. - 144 

XIV. A remarkable Case of Change of Complexion, with Loss of the 
Sense of Smell. By Joseph C. Hutchison, M. D., of Marshall, Saline 
County, Mo. - - - - - - - - 146 

KEVIEW. 

XV. 1. Physician and Patient ; or, a Practical View of the Mutual Duties, 
Relations, and Interests of the Medical Profession and the Community. 
By Worthington Hooker, M. D. 12mo. pp. 453 : New York, 1849. 

-2. D6ontologie M6dicale, ou des Devoirs et des Droits des M6decins dans 
I'Etat actuel de la Civilisation. Par le Docteur Max. Simon. 8vo. pp. 
590. Paris, 1845. 

3. The Moral Aspects of Medical Life, consisting of the " Akesios" of Prof. 
K. P. H. Marx. Translated from the German, with Biographical No- 
tices and Illustrative Remarks. By James Mackness, M. D. 12mo. pp. 
348. London, 1846. 

4. On the Relations of the Physician to the Sick, to the Public, and to his 
Colleagues. By the late Christopher William Hufeland, M. D. 18mo. 
pp. 37. Oxford, 1846. 

5. Guide ou Instruction pour connaitre et choisir un Medecin. P&,r le Dr. 
T. Franck. Traduction Fran9aise, 12mo. pp. 108. Paris, 1846. 

6. Des Devoirs et des Droits des Medecins. Par le Dr. H. Scoutetten. 8vo. 
pp. 27. Metz, 1847. 

7. Des Devoirs des Medecins. Par le Prof. Forget, de Strasbourg. Bull, 
de Therapeutique, tome xxxviii. 

8. Code of Ethics of the American Medical Association, adopted May, 
1847. - - - - - - - - - 149 

BIBLIOGRAPHICAL NOTICES. 

XVI. Surgical Anatomy. By Joseph Maclise, Fellow of the Royal College 
of Surgeons, of England. Part V. : Blanchard & Lea, Philadelphia, 
1851. - - - . . - . - - - 179 

XVII. Elements of Physiology, including Physiological Anatomy. By 
William B. Carpenter, M. D., F R. S., F. G. S., &c. &c. Second Ame- 
rican, from a new and revised London edition ; with one hundred and 
ninety illustrations. 8vo. pp. 556 : Philadelphia, Blanchard & Lea, 
1851. - - . - . - - - - - 180 

XVIII. A Practical Treatise on the Diseases of the Lungs and Heart, in- 
cluding the Principles of Physical Diagnosis. By Walter Hayle Walshe, 

M. D. 12mo. pp. 512: Philadelphia, Blanchard & Lea, 1851. - - 185 

XIX. Lectures on Materia Medica and Therapeutics, delivered in the Col- 
lege of Physicians and Surgeons of the University of the State of New 
York. By John B. Beck, M. D., late Professor of Materia Medica and 
Medical Jurisprudence. Prepared for the Press by Jiis friend, C. R. 
Oilman, M. D., Professor of Obstetrics, etc. in the College of Physicians 
and Surgeons, N. Y. 8vo. pp. 581: New York, Samuel S. and William 
Wood, 1851. _ - - - - - - - -191 

XX. Southern Medical Reports ; consisting of General and Special Reports 
on the Medical Topography, Meteorology, and Prevalent Diseases in the 
following States: Louisiana, Alabama, Mississippi, North Carolina, 
South Carolina, Georgia, Florida, Arkansas, Tennessee, Texas, Califor- 
nia. To bo published annually. Edited by E. D. Fenner, M. D., of 
New Orleans ; Member of the American Medical Association, etc., etc. 
Volume II., 1850, 8vo. pp. 494: New Orleans and New York, 1851. - 194 

XXI. A System of Operative Surgery, based upon the Practice of Surgeons 
in the United States, and comprising a Bibliographical Index and His- 
torical Record of many of their Operations during a period of Two 
Hundred Years. By Henry H. Smith, M. D., Surgeon to the St. Joseph's 



CONTENTS. 



9 



ART. ^ ^ PAGE 

Hospital, &c. &c. Illustrated by numerous steel plates. Phila. : Lip- 
pincott, Grambo & Co., 1852. - - - - - - 197 

XXII. Heport on the Construction of Hospitals for the Insane, made by 
the Standing Committee of the Association of Medical Superintendents 
of American Institutions for the Insane, at its Meeting in Philadelphia, 
May 21st, 1851. 199 

XXIII. The Journal of Psychological Medicine and Mental Pathology. 
Edited by Forbes Winslow, M. 1)., London (published quarterly). Nos. 
1—16. January, 1848, to October, 1851. - - - - - 202 

XXIV. Eighth Report to the Legislature of Massachusetts, relating to the 
Registry and returns of Births, Marriages, and Deaths, in the Common- 
wealth of Massachusetts, from May 1st, 1848, to January the 1st, 1850. 
8vo. pp. 130. - - - - - - _ - 203 

XXV. On Gout ; its History, its Causes, and its Cure. By William Gaird- 
ner, M. D. Second edition, 8vo. pp. 300. London, 1851. - ■ - 200 

XXVI. Operative Surgery, based on Normal and Pathological Anatomy. 
By J. F. Malgaigne, Professeur Agreg6 de la Faculte de Medecine de 
Paris, etc., etc., etc. Translated from the French, by Frederick Brittan, 
A. B., M. D., M. R. C. S. L. Illustrated by Wood Engravings from de- 
signs by Dr. Westmacott. Philada. : Blanchard & Lea, 1851, 8vo. pp. 
565. 213 

XXVII. The Principles and Practice of Obstetric Medicine and Surgery, 
in reference to the Process of Parturition. Illustrated by one hundred 
and forty-eight figures. By Francis H. Ramsbotham, M. D., Fellow of 
the Royal College of Physicians, Consulting Physician in Obstetrics, and 
Lecturer on Obstetric and Forensic Medicine at the London Hospital, 
etc., etc. The sixth American from the Enlarged and Revised London 
Edition. Ta /xev aXka fiai noKEfio^ xdc nf^oJ^oT^Yi -taxyj? ava'Kf^cav rj Texvyj 8s 
(Si^i^stao^ Philadelphia, 1851 : Blanchard & Lea. 8vo. pp. 540. - 214 

XXVIII. Medical Lexicon. A Dictionary of Medical Science ; containing 
a concise Explanation of the various subjects and terms of Physiology, 
Pathology, Hygiene, Therapeutics, Pharmacology, Obstetrics, Medical 
Jurisprudence, &c., with the French and other Synonymes ; Notices of 
Climate and of Celebrated Mineral Waters; Formulae for various Offici- 
nal, Empirical, and Dietetic Preparations, etc. By Robley Dunglison, 
M. D., etc. etc. Eighth edition, revised and greatly enlarged. Phila- 
delphia, 1851 : Blanchard & Lea. 8vo. pp. 927. - - - - 214 

XXIX. Special Anatomy and Histology. By Wm. E. Horner, M. D., 
Prof, of Anatomy, University of Pennsylvania, &c., &c. Eighth edition. 
Illustrated with anatomical figures. 2 vols. Philadelphia : Blanchard 

^ & Lea, 1851, pp. 510 and 500, 8vo. 215 

XXX. The Elements of Materia Medica and Therapeutics. By Jonathan 
Pereira, M. D., F. R. S., and L. S. Third American Edition, enlarged 
and improved by the author, including notices of most of the medical 
substances in use in the civilized world, and forming an Encyclopasdia 
of Materia Medica. Edited by Joseph Carson, M. D., Professor of Ma- 
teria Medica and Pharmacy in the University of Pennsylvania, &c., &c. 
Vol. L : Blanchard & Lea, 1852. 8vo. pp. 1456. - 

The Dispensatory of the United States of America. By George B. Wood, 
M. D., Professor of the Theory and Practice of Medicine in the Uni- 
versity of Pennsylvania, &c. &c., and Franklin Bache, M. D., Professor of 
Chemistry in Jefferson Medical College of Philadelphia. Ninth edition, 
carefully revised. Philadelphia: Lippincott, Grambo & Co., 1851. 8vo. 
pp. 1456. 215 

XXXI. The Physician's Visiting List, Diary, and Book of Engagements 

for 1852. Philadelphia : Lindsay & Blakiston. - - - - 216 

XXXII. A Treatise on Dislocations and Fractures of the Joints. By Sir 
Astley Cooper, Bart., F. R. S., &c. A new edition, much enlarged. Edit- 
ed by Bransby B. Cooper, F. R. S., &c.. Surgeon to Guy's Hospital. 
With Additional Observations, and a Memoir of the Author. A new 
American Edition. Phila.: Blanchard & Lea, 1851. 8vo. pp. 496. 



10 



CONTENTS. 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 

FOREIGN INTELLIGENCE. 



Anatomy and Physiology. 



1. Anatomical arrangement of the 
Vaginal or deep Bursse Mucosce. 

By Mr. Wm. Coulson. - - 217 

2. Supernumerary Fimbriated 
Openings in the Fallopian Tube. 

By M. A. Richard, Jr. - - 218 

3. On the Nerves of the Uterus. 

By M. Boulard. - - - 219 

4. Influence of the Sympathetic 
Nerves and Spinal Cord upon the 
dilatation of the Pupil. By M. 
Julius Budge, professor of the 
University of Bonn, and M. 
Augustus Waller. - - - 219 

5. On the Reunion of Wounds of 



PAGE 

the Spinal Cord, with Restora- 
tion of its lost Functions. By 
M. Brov5^n-S6quard. - - - 220 

6. Farther Experiments on Cada- 
veric Rigidity. By Brown-Se- 
quard. - - - - - 221 

7. Post-mortem duration of the 
ciliary movements in the Human 
Subject. By. M. Gosselin. - 221 

8. Physiological Experiments on 
the Bodies of Executed Crimi- 
nals. By M. Duval. - - 222 

9. Uses of the Pancreatic Fluid. 

By Dr. Bernard. - - - 222 



10. On the varieties of Cod-Liver 
Oil. By M. Donovan, Esq. - 223 

11. On the Medical Employment 
of Extracts of Flesh and Blood. 
By MM. Breslau and Mauthner. 225 

12. Injurious Effects of Camphor 
administered in an Enema. By 
M. Aran. 226 



Materia Medica and Pharmacy. 

13. On the Filix Mas in Tasnia. 
By Professor Albers. - - 226 

14. On the Mineral Waters of Ba- 
den-Baden. By Dr. Sheridian 
Muspratt, F. R. S. E., &c. ^ - 227 

15. A Nevr Method of Preparing 
Powders for use in Medicine. 
By Dr. Wittke. - - - 229 



Medical Pathology 



Therapeutics and Practical Medicine. 



16. On some of the Histological 
Characteristics of Malignant 
Growths. By Prof. Albers, of 
Bonn. 229 

17. On the Local and General Na- 
ture of Tumours. By M. Lebert. 230 

18. On Cancroid Growths. By 

Dr. Bennett. - - - - 232 

19. Ways in which Death occurs. 

By Mr. B. W. Richardson. - 233 

20. Experimental Inquiry into the 
Effects of various Animal Mat- 
ters injected into the Blood. By 
Mr. Millington. - - - 235 

21. The Affinities and Prophylaxis 

of Variola. By Dr. Dcndy. - 237 



22. Analysis of One Hundred and 
Forty-three Cases of Chronic 
Rheumatism, One Hundred of 
which were treated by the Ni- 
trate of Potash and the remain- 
ing Forty-three by Colchicum 
By Dr. John Cargill. 

23. Statistical Report upon Cases 
of Disease of the Heart, occur- 
ring in St. George's Hospital, es- 
pecially in relation to Rheuma- 
tism and Albuminuria. By Dr. 
Barclay. 

24. Spiraea Ulmaria, or Meadow- 
Sweet, in Dropsy. By. M. Tes- 
sier. 



- 240 



245 



246 



CONTENTS. 



11 



Surgical Pathology and Therapeutics, and Operative Surgery. 



PAGE 

25. Symptoms, Pathology, Diag- 
nosis, and Prognosis of Enlarg- 
ed Vaginal Bursee. ByMr. Wm. 
Coulson. - - - - - 247 

26. Treatment of Enlarged Deep- 
seated Bursce. By Mr. Wm. 
Coulson. 249 

27. Treatment of White Swelling 
with Fungosities of the Synovial 
Membrane. By M. Laugier. - 251 

28. On Galvano-puncture in the 
cure of Varicose Veins, and 
of Aneurisms. By Professor 
Schuh. 252 

29. Rupture of the Bladder from 
external pressure. Recovery. 

By Dr. Tomkins. - - - 252 



PAGE 

30. Fracture of the Os Hyoides. 

By Dr. Grunder. - _ - - 253 

31. Necrosis of the Cranial Bones 
after Erysipelas. By M. Larrey. 254 

32. Local application of Wine of 
Squills in Hygroma. By Dr. 
Serrano. - " - - - - 254 

33. Inhalation of Chloroform for 
the relief of Phymosis. By M. 
Guisard. 254 

34. Operation on the Cheek and 
Lower Jaw. Inhalation of Chlo- 
roform nearly fatal. Comments 
on the use of Chloroform in Sur- 
gical Operations. By Edward 
Stanley, Esq. - 255 



Midwifery. 



35. Duration of Pregnancy. By 
Dr. Murphy. - - - - 258 

36. On Kiestein. By Dr. Veit. - 259 

37. Indian Hemp ; its power of 
increasing Uterine Contraction 
during Labour. By Dr. Alex- 
ander Christison. - - - 260 

38. Peculiar form of Thrombus 
occurring during Labour. By 
Dr. Wm. F. Montgomery. - 260 

39. The left arm and hand of a 



child found in a state of Putre- 
scence from Strangulation, the 
Funis being tightly bound round 
it at the upper part. By Mr. 
A. Owens. - _ - - 263 

40. Spurious Menstruation in 
newly-born Infants. By Dr. 
Matthews Duncan. - - - 264 

41. Cases of Purulent Infection. 

By Dr. Charlton. - - - 265 



Medical Jurisprudence and Toxicology. 



42. Case of Poisoning by Tincture 
of Aconite. By B. W. McCready, 

M. D. 268 

43. Orfila on Conicine and Nico- 
tine. 268 

44. Nicotine. By M. Orfila. - 269 

45. Poisoning with Muriate of 
Barytes. By Dr. C. Wolf. - 269 

46. Prussic Acid - - - - 270 

47. On the modus operandi of Ar- 



senic in the exercise of its Anti- 
septic powers. By Dr. Geoghe- 
gan. 270 

48. Case of Feigned Insanity. - 271 

49. Confectionery, how it becomes 
poisonous. - 271 

50. Calcined Magnesia an anti- 
dote to the Salts of Copper. By 
Dr. Boucher. - - - - 272 



Miscellaneous. 

51. On the chemical and general 52. On the Rate of Mortality 
efTects of the practice of Inter- among Persons of Intemperate 
ment in Vaults and Catacombs. Habits. By G. P. F. Neison, 
By Dr. Waller Lewis. - - 273 Esq. 276 



12 



CONTENTS. 



AMERICAN INTELLIGENCE. 



Original Communications. 



Remarkable Case of Intussuscep- 
tion. By M. R. Trevor, M. D. 277 

On Goitre in New Grenada. By 
the Hon. Thomas M. Foote, 
M. D. - - - - - 278 

Case in which thirty-six ounces of 
Chloroform were used in four- 
teen days without any ill effects 



PAGE 

resulting. By W. H. Byford, 
M. D. ----- 279 

Remarkable Case of Hydrocepha- 
lus. By Dr. H. Hinkley. - 280 

Case of Emphysema of the Cellu- 
lar tissue occurring during La- 
bour. By L. S. Joynes, M. D. 281 

Case of Ovariotomy. By Ezra P. 
Bennett, M. D. - - - 282 



Domestic Summary. 



Gastrotomy in a case of Extra- 
Uterine Pregnancy. ' By Dr. 
Bradley. - - - - _ - 283 

Successful removal of the Parotid 
Gland. By Dr. A. J. Wedder- 
burn. 283 

Gastrotomy. By Dr. S. B. Malone 
and Dr. D. B. Gorham. - - 283 

Horn five and three-quarters inches 
in length upon the head of a 
woman. By Dr. A. L. Sands. 284 

Popliteal Aneurism successfully 
treated by Compression. By 
W. H. Van Buren, M. D. - - 284 

Stomatitis of Pregnant and Nurs- 



ing Women. By Dr. Jno. Evans 
and Dr. D. L. Guigin. - - 284 

Wound of the Abdomen penetrat- 
ing through the coats of the Sto- 
mach ; protrusion of this organ. 
By Dr. C. W. Ashby. - - 285 

Colica Pictonum from the medical 
employment of Acetate of Lead. 
By Dr. L. S. Joynes. - - 285 

Tracheotomy in Croup. By Dr. 
Carter P. Johnson. - - 285 

Hydrastis Canadensis in Gonor- 
rhoea. _ By Dr. P. C. Gooch. - 286 

Transactions of the American Me- 
dical Association. - - . 286 



THE 



AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOE JANUARY 1 8 52. 



Art, I. — Medical and Surgical Notes of Campaigns in the War with 
Mexico, during the years 1845^ 1846^ 1847, and 1848. Bj John B. 
Porter, M. D., Surgeon U. S. Army. 

^^It is by tracing diseases as they affect considerable masses of men, placed 
as nearly as possible under the same external circumstances, that we gain the 
surest and most satisfactory evidence in respect to the cause of disease; and 
hence it is that the experience of those medical men who are employed in our 
fleets and armies is so valuable.'^ 

Admitting the correctness of the above statement, it is the duty of medical 
officers, serving with large bodies of men, to contribute to the investigation of 
the numerous diseases to which troops are liable in the field. Briefly, there- 
fore, an endeavour will be made to throw a mite into the common treasury. 

The " Army of Occupation," as it was termed, commanded by General 
Tciylor, was partially collected in August and September, and fully organized 
early in October, 1845, The occupation of the position of Corpus Christi 
being regarded by the Republic of Mexico as a hostile demonstration, and a 
quasi-war immediately following, the year 1845 may properly be considered 
the first of the war. 

The village of Corpus Christi is on the bay of the same name, in lat. 27° 
49' 27" north; Ion. 97° 16' west. Our extreme left rested on this village, 
which contained the genercxl hospital of the army, and the storehouse for 
medical supplies, with a guard. Only a brief description of the encampment 
is required. 

On landing from the bay, we found ourselves directly in camp, near the 
water's edge, elevated only a few feet above high-water mark. Passing on to 
No. XLY.— Jan., 1852. 2 



14 Porter, Surgical Notes of the Mexican War. [Jan. 

the front, a distance varying from a quarter to half a mile, is a steep hill, 
one hundred and fifty or two hundred feet in height ; and, having ascended 
this, we reached the table land of the rich prairie country, covered with wood 
three-quarters of a mile or a mile further in front. The main part of the 
army occupied the low sandy plain near the water's edge ; but passing up 
from the left and the village to the right, crossing an insignificant creek or 
rivulet, was the camp of General Worth, on a bluff several feet above the 
centre and left of the army. 

Each regimental hospital had two or three large hospital tents, and when 
these were too much crowded, or particularly severe and long-continued cases 
occurred, patients were transferred to the general hospital, which was a long 
framed building in the village of Corpus Christi, The hospital tents were 
fitted up with stoves in winter, and were quite comfortable. Early in October, 
the assignment of medical officers was made, and I was stationed with the 
third infantry. 

The army had full employment for the fall and winter. In good weather, 
the drills were uninterrupted, and in bad weather the men had quite enough 
to do to make themselves comfortable, provide fuel, &c. A few words in 
relation to the climate. 

October. — In this month, the days were warm and the nights cool, often 
chilly. There was a good deal of sickness, principally diarrhoea and dysentery. 
Catarrhal affections were also common. Indeed, the whole army, in this month 
and part of the next, might be considered a vast hospital, few of the officers 
or men escaping an attack of diarrhoea, and hundreds were affected who were 
never entered on the sick reports. 

November. — Diarrhoea and dysentery were prevalent. The first part of the 
month was warm; the middle variable, generally warm days and cool nights; 
and the last part very inclement. A drizzling rain began at 6 P. M. on the 
29th, and continued through the night, freezing as it fell, and ceased at 7 
A. M., on the SOth. Quantity, 0-12 inches. On the morning of the 30th, 
the ground, the trees in the vicinity, and our tents, were covered with thick 
ice. Thermometer for two days as follows : — 

Daily Metallic bulb. 

S. R. 9 A.M. 3 P.M. 9 P.M. mean. S.R. 3 P.M. 

November 30th, 30 30 41 31 35.5 30 36 
December 1st, 23 37 44 40 33.5 33 39 

These two days were the coldest of the winter, and the troops suffered 
greatly. The fifeh were so benumbed by the cold that they were caught in 
large quantity by the hand, particularly on the bar at the mouth of the River 
Nueces, a short distance above General Worth's camp. Ice occurred half 
an inch thick. 

December was wet, cloudy, cold, and inclement; yet there was a sensible 
decrease of sickness, the number of cases being one-third less than in the pre- 
ceding month, and nearly one-half less than in October. 

January, — The monthly mean of the thermometer was greater than in 
December; but it was, nevertheless, a wet, cold, and very uncomfortable 
month. Bather more sickness than in December. 

I am indebted to the kindness of surgeon N. S. Jarvis, in charge of th^ 



1852.] 



Porter, Surgical Notes of the Mexican War. 



15 



general hospital, for the following abstract of the meteorological register of 
the general hospital, Corpus Christi : — 

November. 

Daily Metallic bulb. 

S. R. 9 A.M. 3 P.M. 9 P.M. mean. S.R. 3P.M. 

Mean of therm., 57 62.60 67.90 62. 62.45 51.2 61.2 

Clearness of sky, 3.56 3.2 4.73 6.10 

Highest degree, 89. Lowest, 30. Kange, 59°. Highest daily mean, 81°. 
Lowest, 35.5°. Range, 45.5°. Rain, 3.56 inches. 

December. 

Daily 

S.R. 9 A.M. 3 P.M. 9 P.M. mean. 

Mean of therm., 47.22 50.06 57.61 52.50 52.35 
Clearness of sky, 1.90 1.90 1.70 3.12 

Highest degree, 72. Lowest, 23. Range, 49°. Highest daily mean, 66.5°. 
Lowest, 33.5°. Range, 33°. Rain, 4,7 inches. 

January. 

Daily Metallic bulb. 

S.R. 9 A.M. 3 P.M. 9 P.M. mean. S.R. 3 P.M. 

Mean of therm., 50.64 53.90 63.87 56.77 57.25 47.48 57.32 
Clearness of sky, 3.51 3.54 3.80 3.25 

Highest degree, 84. Lowest, 30. Range, 54°. Highest daily mean, 74°. 
Lowest, 41.5°. Range, 32.5°. Rain, 3.96 inches. 

In my notes of December 31st, 1845, is the following: "For several 
weeks past, the weather has been very wet and exceedingly cold, the mercury 
on the 1st inst. being as low as twenty-three degrees, and ice half an inch in 
thickness was formed. ^ Northers' have been frequent, and the changes of 
temperature have been very sudden and great ] hence the sickness and greater 
number of deaths. The number of sick has varied from 350 to 475 during 
the month, having been as high as 550 in the middle of November. The 
army is in better condition now ; but still, on account of poor shelter and 
scarcity of wood, there is yet a good deal of suffering.'^ 

I am indebted to Captain (now Colonel) Bliss, the Adjutant-General of the 
Army, for permission to copy the daily reports of the strength and sickness 
of the army for four months. . An abstract is presented. 

September. — Number of sick (constantly) per 1000. Officers, 93. Non- 
commissioned officers, musicians, and privates, 115. Deaths from disease, 6; 
or, 2.44 per cent, of the average number of cases, officers, and men, for the 
month, or 2 per cent, of the greatest number sick on any one day of the 
month. But a fallacy may be noticed. There might have been 500 or 
1000 cases during the month, and the mortality would then be 1.2 per cent, 
or 0.6 per cent. Four deaths from the explosion of the steamer Dayton not 
included. 

October. — Number constantly sick per 1000. Officers, 90. Men, 118. 
Deaths, 5, or 1.25 per cent, of officers and men, average for the month. For 
the greatest number of cases in any one day, 0.95 per cent.; and for 500 or 
1000 cases, the mortality would be 1 per cent., or 0.5 per cent. 

Noremher. — Number per 1000 constantly sick. Officers, 113. Men, 144. 
Deaths, 12; or, 2.4 per cent, of the monthly average, and 2.19 per cent, of 
the greatest daily reports. Admit 500 or 1000 cases in the month, and the 
mortality would be 2.4 and 1.2 per cent, respectively. 

December. — Number per 1000 constantly sick. Officers, 76. Men, 126. 
Deaths, 19; 4.62 per cent, of the monthly average, and 3.9 per cent, of the 



Metallic bnlb. 
S.R. 3 P.M. 

45.16 52.70 



16 



Porter, Surgical Notes of the Mexican War. 



[Jan. 



greatest daily report, 
and 1.9 per cent. 



Admit 500 or 1000 cases, and the mortality is 3. 



Abstract of the Report of Sick for the Third Infantry, quarter ending December 

31, 1845. 

Diseases. 
Fevers, of all kinds. 
Diarrhoea, .... 
Dysentery, acute and chronic, 
All others of digestive system, 
Catarrh, .... 
All others of respiratory system 
Brain and nervous system, 
Genitals, .... 
Rheumatism, acute and chronic 
Abscesses and ulcers, 
Wounds and injuries, 
All other diseases. 



Total taken sick. 



October. 


November. 


December. 


Total 


15 


16 


12 


43 


CO 

DZ 


37 


10 


109 


31 


45 


19 


95 


34 


20 


9 


63 


30 


19 


18 


67 


I, 1 


4 


6 


11 


1 


6 


3 


10 


4 








4 


, 7 


10 


8 


25 


19 


14 


5 


38 


7 


7 


20 


34 


24 


34 


13 


71 


235 


212 


123 


570 



Remaining sick at last report, 

Aggregate, 

Sent to General Hospital, 
Returned to duty. 
On furlough, 

Discharged (for disability), 

Died, 

Remaining sick, . 



One death, from typhoid pneumonia, in November. 

Mean Strength. 



60 

630 

23 
551 
4 
7 
1 
44 

630 





Officers. 


Men. 


Total. 


October, 


30 


470 


500 


November, 


30 


446 


476 


December, 


29 


438 


467 


Average, 


291 


451 


481 



Abstract of the Report of Sick for the Third Infantry, quarter ending March 31, 

1846. 

Diseases. 

Tevers, 

Diarrhoea, .... 
Dysentery, acute and chronic. 
All others of digestive system, 
Catarrh, .... 
All others of respiratory system, 
Rrain and nervous system. 
Genitals, .... 
Serous and exhalant vessels, . 
Rheumatism, acute and chronic. 
Abscesses and ulcers. 
Wounds and injuries, 
All others. 

Total taken sick. 



January. 


February. 


March. 


Total. 


4 


7 


6 


17 


4 


2 


15 


21 


15 


8 


3 


26 


11 


5 


3 


19 


34 


23 


10 


67 


2 


1 





3 


6 


4 


3 


13 


3 


1 





4 


1 


2 


1 


4 





3 


4 




8 


5 


3 


16 


15 


16 


8 


39 


12 


14 


9 


35 


115 


91 


65 


271 



1852.] Porter^ Surgical Notes of the Mexican War. 17 

Taken sick, 271 

Kemaining last report, .... 44 

Aggregate, . . . .315 

Sent to General Hospital, .... 31 

Returned to duty, 262 

On furlough, ...... 1 

Discharged (for disability), ... 5 

Deaths, 1 

Eemaining, , . . . . . 15 

315 

Mean Strength. 

Officers. Men. Total. 

January, . . . 27 423 450 

February, ... 27 411 438 

March, ... 26 374 ^ 400 

Average, . . 26f 403 429 



One deathj in J anuary, from peritonitis. The autopsy revealed the cause ; 
a chronic abscess of the liver had opened into the cavity of the peritoneum, 
producing intense inflammation. It is to be recollected that several patients 
were sent to the general hospital, and that some died there, so that the above 
deaths are not all which ought to be recorded for the third infantry in six 
months. This regiment was in the entire charge of surgeon N. S. Jarvis, in 
the month of March. 

The causes of disease at Corpus Christi were: 1. Bad water. 2. Bad 
tents. 3. Bad air. 4. Hot days and cold nights, or variable temperature. 
5. Scarcity of fuel. 

1. Bad water. — This was brackish, and as bad as could be imagined through- 
out the whole camp ; worst on the right of the army. For a time, until the 
men became somewhat habituated to it, they might as well have used a solu- 
tion of sulphate of magnesia ; hence the numerous bowel affections, both on 
the sick list, and among those who never came upon it. 

2. Bad tents. — It is a peculiarity of our service that men are better paid, 
better clothed, and better fed than those of any army in the world, and well 
taken care of wlien sick; while they are worse lodged, both in peace and war, 
than any other troops. In time of peace, our barracks, where there are bar- 
racks, are confined, out of repair, ill ventilated, and in every way badly con- 
structed. In time of war, the tents are of the worst quality. At Corpus 
Cliristi during rain, the water drizzled through the new tents, so as to wet 
everything, and many of the tents were worn out and useless. Officers 
could do something in the way of protection, by means of rubber coverings 
to their camp-beds, &c. ; but what could the poor soldier do ? In a common 
tent were three of my patients, a poor woman of the third infantry and her 
twin children, the latter in their second or teething summer, with cholera 
infantum, and the mother with chronic dysentery. They were all, at one 
time, in extremis ; but fortunately they escaped with their lives, and in 1849 



18 VoYtQV, Surgical Notes of the 3Iexican War. [Jan. 

were all alive, and hearty. During the winter, lumber was procured from 
New Orleans by order of General Taylor, and tent-fioors were made, which 
added greatly to the comfort of both officers and men. 

3. Bad air. — The sun acting on a soil with abundance of water a few 
inches below the surface, as at Corpus Christi, is reckoned, by some writers, a 
fertile source of disease. The heavy rains saturated the plain and table-land 
above, and stagnant pools remained for days and weeks in all parts of camp. 

Privies. — Attention was given to their police, but in a whole army of diar- 
rhoea-patients, with camp followers, the police of the environs was necessarily 
bad. As loDg ago as 1748, Sir John Pringle ascribed much of the camp 
dysentery to this source. But the great source of infection seems to be the 
privies, after they have received the dysenteric excrements of those who first 
fall ill." Dr. Kush has some remarks on the same subject. Yide Eush's 
Pringle, pp. 61,-89, 90, 91, 226. The above seems to have been efficient 
causes of disease, producing animalculas, fungi, gases, or malaria, as may be 
determined. 

4. Sot days, and damp and cold nights — variable temperature. This was 
common in October. November 7th — thermometer at 3 P. M. 89°; 9 P. M. 
67° ; range 22°. This is an extreme instance, but similar changes were not 
uncommon. 

S. R. 9 A.M. 3 P.M. 9 P.M. Daily mean. 

Nov. 8th, . . 51 56 63 53 57° 

" 9th, . . 46 55 63 53 54.5° 

5. Scarcity of fuel. — This essential article was scarce in proportion to its 
necessity. When the cold rains commenced, the table-land above camp, 
across which our fuel had to be hauled, was a complete slough. The hospitals 
were generally well supplied, but the rest of the army suffered extremely. 

February was generally dry, and the weather beautiful. The troops — 
cavalry, light-artillery, infantry, and light-infantry — were thoroughly drilled 
in the field, and at target-firing. The sickness was less than in any previous 
month. Orders came from Washington for the army to move to the Rio 
G-rande, and from this time active preparations were going on in all depart- 
ments for taking the field. The field hospitals and stores were got in readi- 
ness, and those men who were unable to march were sent to the general 
hospital, which was transferred to St. Joseph's Island. My station was 
changed to the artillery battalion and Duncan's battery — 12 companies in all. 

March 9th, 1846. — Our brigade, the first, under General Worth, composed 
of the artillery battalion, 8th infantry, and Duncan's battery, took up the 
line of March; Col. Twiggs, with the cavalry, and Einggold's battery, 
marched the day before; on the 10th, second brigade; and on the 11th, the 
third brigade and Bragg's battery. 

The weather this month was fine; there was little rain, and the roads were 
good. There was but little sickness, and the cases were of small importance. 
On the 20th, the Colorado was crossed, and on the 2'8th our whole army 
encamped on the left bank of the Eio Grande, opposite Matamoros. 



1852.] 



Porter, Surgical Notes of the Mexican War. 



19 



Abstract of the Report of Sick of the Artillery Battalion and Duncan's Battery, 



for quarter ending Zlst 3farch, 1846. 
Diseases. January. February. March. Total. 

Fevers, 1 2 2 5 

Diarrhoea, .... 20 2 4 26 

Dysentery, acute, . . 8 17 14 . 39 

All others of digestive system, 7 5 3 15 

Catarrh, .... 45 38 18 101 

All others of respiratory system, 2 2 

Brain and nervous system, .3 3 6 

Kheumatism, acute and chronic, 7 9 5 21 

Abscesses and ulcers, . . 20 3 11 34 

Wounds and injuries, . . 9 9 10 28 

All other diseases, . . 9 24 9 42 

Total taken sick, 131 109 79 319 

Remaining last report, .... 61 

Aggregate, .... 380 

Sent to General Hospital, .... 26 
Heturned to duty, . . . . .331 
Discharged (disability), .... 3 

Deserted, 1 

Died,_ ........ 1 

Remaining sick, 18 

380 

One death in January from continued fever. 

Mea7i Strength. 

Officers. Men. Total. 

January, ... 39 512 551 

February, ... 40 513 553 

March, ... 41 536 577 

Average, 40 520 560 



Surgeon Hawkins was in charge of the battalion until February 26 th. 

April was an uncomfortable month. The rain fell in torrents, and the 
whole country between the Rio Grande and Point Isabel (where General 
Taylor had established the main depot) was at one time nearly impassable. 
Our tents were of the Corpus Christi order ; therefore but little protection was 
expected from them. A large field-work had been laid out, afterwards known 
as Fort Brown, and on this the officers and men incessantly laboured ; strong 
guards, pickets, and videttes were constantly on duty ; the weather was be- 
coming warmer — in a word, every one had as much as he could attend to ; 
yet the sickness was not great, nor were the cases important. Towards the 
last part of the month, the rains ceased, fortunately for us, for the crisis was 
approaching. 

J/ay 1st, 1846. Leaving a garrison to defend Fort Brown, the army 
marched to Point Isabel at 3 o'clock, P. M. We marched until past 
1 o'clock at night, then bivouacked until the morning, and reached Point 
Isabel at 12 M. of the 2d. On the od, the bombardment of Fort Brown 



20 Porter^ Surgical Notes of the Mexican War. [Jan. 

commenced, whicli we could distinctly hear. Until the middle of the 7th, 
our men laboured hard on the works at Point Isabel, and at 3 P. M. our 
little army started on the return march to the Hio Grande — marched about 
nine miles. 

3Iai/ Sth. Marched about 7 A. M., and about 1 o'clock P. M. information 
was given that the Mexican army was in our front. "We advanced slowly in 
order of battle, and in a short time came in sight of the enemy. The army 
was halted, the men procured water and filled their canteens, the wagon train 
was parked, and everything got ready for action. We again advanced slowly, 
and about 3 o'clock P. M. the battle of Palo Alto began. I went into action 
just in rear of the battalion, and the cannon-shot of the enemy, passing over 
our ranks e7i ricochet, fell thickly around me. Soon our men began to fall, 
and the medical officers had plenty to do in the hospitals. The battle did 
not end until half an hour after sun-down. It was fought almost wholly by 
the artillery ; the loss was not great, but the wounds were severe, and the 
surgeons were employed with the wounded until late at night. The principal 
loss was in our brigade, at this time commanded by Col. (now G-eneral) Bel- 
knap, the enemy having attempted to turn that flank of our army. 

3Ia2/ 9th. Early this morning, the enemy was seen moving off in the 
direction of Matamoros. The surgeons were busily engaged with our own 
and the Mexican wounded left upon the field, and about 1 o'clock P. M. they 
were all started off to Point Isabel, where hospitals had been made ready. 
Just as we were prepared for a forward movement, a melancholy accident 
occurred. Lieut. J. E. Blake, Topographical Engineer, who had the day 
before most daringly reconnoitred the enemy in presence of both armies, was 
mortally wounded by the accidental discharge of his own pistol. It was done 
while in the act of sitting down, the pistol having become disengaged, in some 
way, from the belt at the same time. Being the nearest surgeon on the 
ground, I was called, and hurried to the spot. The pallid countenance and 
cold perspiration told the tale. The bullet, not much larger than an infantry 
buckshot, had passed into the perineum a little to the right of the median 
line; had passed through the bladder, intestines, stomach, liver, diaphragm, 
and right lung, and was taken out by an incision through the integument, 
between the sixth and seventh ribs, with stercoraceous matter. Having done 
this, I was obliged to march, and poor Blake was turned over to the medical 
officer in reserve. He died in an hour or two after. 

At 2 o'clock P. M., our army again took up the line of march, and about 
3 o'clock our light-infantry, under Captain (now Col. and Inspector-General) 
McCall, received the first fire of the enemy at Resaca de la Palma ; and the 
different regiments were brought up to the field of action as rapidly as possi- 
ble. The battle was finally ended by the charge of the 8th Infantry (reserve), 
which broke the enemy's centre, took the artillery, and secured a complete 
victory. This was near sundown. The field where the main struggle took 
place presented a sad appearance ; the bodies of men, horses, arms, vehicles, 



1852.] 



Porter, S^ir)jical Notes of tlie Mexican War. 



21 



&c. were scattered in all directions. That night forcibly reminded one of the 
beautiful lines of Campbell : — 

" Our bugles sang truce, for the night clouds had lowered, 
And the sentinel stars set their watch in the sky, 
And thousands had sunk on the ground overpowered, 
The weary to sleep, and the wounded to die/' 

The battle was ended, but the labours of the surgeons had scarcely begun. 
Another and more arduous night's work was before us, and Surgeon Wright 
(to whose talents and skill I may be allowed to bear testimony) and myself 
were the only medical officers of the brigade, our two assistants having been 
detached this morning on other duty. Our wounded were much more nume- 
rous than the day before, and a large number of wounded Mexican officers 
and soldiers had been left in our hands. 

May lOtli. Our duties early recommenced, and the whole medical staff was 
engaged much of the day with our own and the Mexican wounded. On the 
11th, until three o'clock P. M., we were busily engaged in getting off our 
wounded to Point Isabel, expecting warm work before Matamoros; and the 
Mexican wounded were given over to their surgeons. On the 12th, a large 
number of Mexican wounded were sent across the river to Matamoros, and on 
the 18th we crossed the Rio Grande, and took quiet possession of the town. 



Report of the hilled and icounded of the Army of Occupation during the suc- 
cessive actions of Palo Alto, fought on the Sth, and Resaca de la Raima, 
on iJie 9 th May, 1846. 





FiKST Day. 


! Second Dat. 

! 




Killed. 


Wound- 
ed. 


Aggre- 
gate. 


illed 
ed. 


Killed. 


Wound- 
ed. 


Aggre- 
gate. 


illed 
led. 




Corps. 


Oflicers. 


Men. 


Officers. 


j Men. 


Killed. 


Wounded. 


Aggregate k 
and wound 


Officers. 


Men. 


Oflicers. 


Men. 


Killed. 


Wounded. 


Aggregate ki 
and wounc 


S 

rt 
<! 


General Staff 




















1 






1 


1 


1 


Dragoons 








6 




6 


6 


1 


10 




8 


1] 


8 


19 


25 


Ringgold's battery 


1 


1 




1 


2 


1 


3 








4 




4 


4 


7 


Duncan's " 








4 




4 


4 
















4 


Artillery battalion 




3 


1 


8 


3 


9 


12 




3 




7 


3 


7 


10 


22 


3d infantry 


















2 


1 


4 


2 


5 


7 


7 


4th " 




1 


2 


1 


1 


3 


4 


1 


3 


1 


4 


4 


5 


9 


13 


5th " 








5 




5 


5 




10 


3 


25 


10 


28 


38 


43 


8th " 




4 




16 


4 


16 


20 


1 


7 


7 


25 


8 


32 


40 


60 




1 




3 


41 


10 


44 


54 


1 3 


35 


13 


77 


38 


90 


128 


182 



Recapitulation. 



First day. 


Second day. 


Both days. 


Aggregate 
ist day. 


y 

=i 

=c ^ 
t-O 

< 


Officers. 


Men. 


Officers. 


Men. 


Officers. 


Men. 


4 


50 


16 


112 


20 


162 


54 


128 



22 



Porter, Surgical Notes of the Mexican War. 



[Jan. 



There is a discrepancy between this and the medical reports, owing pro- 
bably to our having numbered the mortally wounded, who died soon after, 
and these are enumerated as killed in the above table. 

Thus ended an arduous and an anxious campaign. 

It has been so fashionable to make heroes, that our little army at Palo Alto 
and Resaca de la Palma (not omitting the garrison of Fort Brown) is nearly 
overlooked. But it should not be forgotten, that this little army of 2270 
officers and men (Greneral Taylor himself says that at Palo Alto it "did not 
exceed, all told, 2300'^) met 6000 Mexican regulars, besides ra,ncheros, 
the best army Mexico had during the war, and gained a complete victory. 
It should not be forgotten that at Resaca de la Palma the enemy's army was 
strongly posted in the chaparral and behind a ravine; that this position was 
strongly defended by artillery, which was powerfully supported by the best 
Mexican infantry; and that this little army gained a complete victory — our 
trophies being eight cannon, several standards, several hundred stands of arms, 
many prisoners, large quantities of ammunition and baggage, and a large num- 
ber of pack-mules, the baggage, plate, and papers of Greneral Arista, the bag- 
gage of G-eneriil Ampudia, &c. &c. These things ought not to be overlooked. 

Our brigade encamped near the Rio Grrande, a short distance below Mata- 
moros, where it remained until after the middle of July. The diseases were 
much the same as heretofore, diarrhoea and dysentery predominating. 

Abstract of Report of Sick for the quarter ending June SOth, 1846. — Artillery 
battalion* and Duncan's battery, twelve companies in the first part of April, 
and eleven companies for the remainder of the quarter. 



Diseases. 


April. 


May. 


June. 


Total 


Fevers .... 


2 


7 


14 


23 


Diarrhoea .... 


3 


3 


19 


25 


Dysentery, acute 


. 29 


26 


15 


70 


All others of digestive system 


7 


9 


8 


24 


Catarrh .... 


. 16 


5 


16 


37 


All others of respiratory system 


1 


1 





2 


Brain and nervous system , 


4 


8 


2 


14 


Genital organs 





1 


2 


3 


Rheumatism, acute 


6 


3 





9 


Abscesses and ulcers . 


. 11 


18 


4 


33 


Wounds and injuries , 


6 


33 


14 


53 


All others .... 


. 19 


8 


35 


62 


Total taken sick . 


. 104 


122 


129 


355 


Remaini 


ng last 


report 




18 



Aggregate 

Sent to General Hospital 
Returned to duty 
Deserted 

Died .... 
Remaining sick . 



373 

23 
314 
1 

5 
30 



o / o 



* The artillery battalion was made up of companies from the first, second, third, and 
fourth regiments of artillery, armed as infantry, and organized as a regiment. 



1852.] 



Porter^ Siirrjical Notes of the Mexican War. 



23 



Mean Strength. 



Officers. 


Men. 


Total. 


36 


454 


490 


32 


393 


425 


34 


410 


444 


Average 




453 



April 

May 

June 



One death from acute dysentery in June, four mortally wounded at Palo 
Alto and Resaca de la Palma. Deaths in General Hospital not included. 

Hitherto little has been said of the treatment of disease. At Corpus 
Christi, and on the Rio Grande, fevers were generally amenable to the power 
of quinine. A quantity of salicine had been sent out to the army for trial, 
but experience proved that it could not be relied upon in serious cases. Diar- 
rhoea and dysentery on the Eio Grande were treated pretty successfully in the 
usual mode, regard being had to climate and exposure. When these diseases 
had continued a few days, or the evacuations had become somewhat more 
natural in appearance than at first, the combinations of sulphates of copper and 
opium, and acetate of lead and opium, were successfully employed. Full 
details of the treatment are not necessary. 

In April, an ofiicer of the general staff applied to me for relief from hemor- 
rhoids. He stated that the itching was so tormenting that he could rest but 
little at night ; that he would give anything in the world to be relieved ; and 
that he had tried almost everything," naifling several applications. I advised 
him to apply tincture of iodine, which he did, and the next day he informed 
me that he had slept better than for a long time previously. 

In the same month, while the whole army was engaged in throwing up the 
works of Fort Brown, the weather being wet, an officer of artillery had an 
attack of acute rheumatism in the right shoulder-joint. The parts around the 
joint, with the upper parts of the arm, were swollen, painful, and very tender 
to the touch; tincture of iodine was freely applied with great benefit, and in a 
short time he was fit for duty. He was in the battles of the 8th and 9th 
May, in the most active manner. 

Tincture of iodine was in common use, locally, for ulcers and inflammations, 
both in the camp at Corpus Christi and during the subsequent campaigns. 

Notwithstanding the numerous cases, the troops could not be considered 
sickly; recovery was rapid, and convalescence was not slow, so that the patient 
was soon returned to duty. This was owing, probably, to the heavy rains in 
the last of May and in June, which served the double purpose of preserving 
the health of the army and rendering the Rio Grande navigable for steam- 
boats. The residents of Matamoros say that, when the river rises so as to fill 
all the lakes and lagoons about town, the summer is healthy ; but when the 
river is low and the lagoons are not full, it is sickly. There is little doubt of 
their correctness. In 1846, the lakes and lagoons were full; hence the com- 
parative mildness of our diseases, and the small mortality; for in the next 



24 



Porter^ Surgical Notes of the Mexican War. [Jan. 



year (1847) there were great sickness and mortality, and the river was low, 
the lagoons containing but little water. 

July l^th. Our brigade embarked on steamboats for Camargo, on the San 
Juan, about four miles above its junction with the Rio G-rande. Although 
the banks of the San Juan are near fifty feet above low-water mark, the river 
had this year overflowed them, and done much damage to the town and adja- 
cent country. A large deposit was left, the weather was hot and rainy, and 
if our army had remained a much longer time, there would have been con- 
siderable sickness. As it was, there was an addition to the sick report, and 
the cases were more severe than at Matamoros. 

Aug. Our brigade took up the line of march for Seralvo, which it 

reached on the 25th. The treatment of diarrhoea and dysentery, both here 
and at Camargo, was nearly the same as for the same diseases at Matamoros. 

Sept. 14ith. Marched from Seralvo, with the main army, for Monterey, in 
front of which we encamped on the 19 th, between three and four miles from 
the town, by a small stream formed by the junction of numerous springs issu- 
ing from the limestone formation, and a large grove of pecan trees, called by 
the Mexicans M Bosque cle St. Domingo, and by the Americans Walnut 
Grove. 

20th. G-eneral Worth's division, consisting of Duncan's and MackaU's bat- 
teries, the artillery battalion, the 5th, 7th, and 8th infantry regiments, Hay's 
Texan mounted rangers, and a company of volunteers from Louisiana, moved 
from the main camp about twelve o'clock, M., for the rear of Monterey, to 
find and take possession of the Saltillo road, and attack the enemy's defences 
on that side of the town. After a reconnoissance, and approaching the enemy's 
position on the Loma de Inclej^enclencia, the summit of the height above the 
Bishop's palace, we bivouacked for the night. A heavy rain came on about 
sun-down, and a drizzling rain continued part of the night. 

21st. Early this morning, the division was put in motion, passing under the 
shot and shells from the enemy's batteries, and after some fighting in front 
took possession of the Saltillo road. Being the senior medical officer with the 
division, I was directed by General Worth to organize a general hospital for 
the wounded, the preparations for which had been made at Camargo and Se- 
ralvo. To-day the hill called Federacion, and the small fort La Soldada, were 
stormed, and our wounded were afterwards removed to a new position, and 
nearer the field of operations. Heavy rain came on before sunset, and the 
night closed in dark and dreary. 

22d. The Loma de Independencia was carried long before sunrise, and dur- 
ing the day the Bishop's palace, situated upon and midway the southern slope 
of the hill Independencia, fell into our hands. Our wounded were removed 
to the palace before night. 

22>d. The division moved about four o'clock, P. M., to the assault of the 
town, and discharges of artillery and musketry continued until long after dark. 
Apprehending a severe loss in this attack. General Worth directed me to 



1852.] 



Porter, Surgical Notes of the Mexican War. 



25 



remain in the general hospital at the palace, and receive the wounded as they 
were sent from the field of battle. Preparations were made for early action 
to-morrow. 

24^7i. No fighting ; and the articles of capitulation were signed, by which 
the town, fortifications, &c., fell into our hands. 

25^7i. Our wounded were removed about half a mile to the residence of 
G-eneral Arista, a beautiful place, with delightful gardens, plenty of water, &,c., 
where the general hospital for our division was permanently established. 

Some cases of gunshot wounds will be given, with a few remarks. 

Wounds of the head, unless slight, may be considered dangerous. 

Case I. — Private Amos Collins, Company A, 3d Artillery, was wounded 
on the 22d of September. He received a superficial shot through the right 
shoulder, which was not serious. A musket shot passed through the scalp 
just above the right ear, which was not considered, at the time, as more than 
a slight wound. It proved troublesome, however; inflammation of the cellular 
membrane came on, and free incisions had to be made. He was a drunken 
fellow, which was the main cause, probably, of the inflammation. Ptecovered. 

Case II. — Private Nathaniel White, K, 7th Infantry, in storming the 
heights in rear of Monterey, September 21st, received a musket-shot on the top 
of the head, which ran through the scalp, ploughing from front to the back part 
of the head, the end of the furrow being deepest, and laying bare the pericra- 
nium. This wound Wiis much more serious than Case I., but was less trouble- 
some, though patient was longer in hospital. Eecovered. 

Case III. Concussion. — On taking possession of the Bishop's palace, at 
Monterey, for a hospital, on the afternoon of 22d of September, a number of 
killed and wounded Mexican soldiers were found in the Plaza. One of them 
was counted among the killed, but on close examination life was found not to 
be extinct, though the pulsation of the radial arteries could not be felt ; he 
was therefore placed with his wounded comrades, and made as comfortable as 
our circumstances would permit, expecting that he would, of course, be a dead 
man next morning. The wound was inflicted by the explosion of one of our 
shells after we had taken the hill Independencia, and the scalp was badly lace- 
rated by the fragments. He was considered past hope. Next morning, to 
our astonishment, he was found sitting up, and was able to take a little nourish- 
ment. He. was soon sent to the Mexican hospital, and we lost sight of him. 

Case IY. — Captain Randolph Ridgely, 3d Artillery, and commanding bat- 
tery of light artillery after the death of Major Ringgold, was riding rapidly 
through tlie sti-eets of Monterey, on the 25th of October, 1846, when his horse 
made a false step and fell prostrate on the pavement. Captain R. fell with 
the horse, the head striking the pavement first, and he was taken up in a state 
of insensibilit}^ Being the nearest medical man, I was sent for, and found 
the Captain insensible; the pupils of the eyes dilated; blood flowing from the 
ears, &c. ; and fears were at once entertained that the injury would prove fatal. 
He remained in this condition, unless rallying a little after a copious bleeding 
from the arm, and died on the 27th. Permission could not be obtained from 
his next friend for an examination post mortem, but there was probably rup- 
ture of the brain and extensive extravasation. This case is given entirely from 
memory. Being quite unwell at the time with the prevailing intermittent, I 
was under obligations to Assistant-Surgeon De Leon for remaining with me 
in attendance to the last. 



26 



Porter, Surgical Notes of tlie Mexican War. 



[Jan. 



Case V. — This case may come in here, though, like the preceding, not a 
gunshot wound. In the summer of 1847, a train of teams, encamped carelessly 
a few miles from Vera Cruz, was suddenly attacked in the night by Mexican 
guerillas. One of the teamsters received desperate wounds ; one of the hands 
was cut off at the wrist, and there were sabre cuts on the head, the most severe 
being on the upper and back part, by which a portion of the posterior lobe of 
the cerebrum was removed to nearly the depth of two inches. On his arrival 
at Vera Cruz, he was considered moribund, both from the dreadful wounds on 
the head and loss of blood; and for a long time he was in a desperate condition. 
This case was seen several times in the course of treatment, with Assistant- 
Surgeon Laub, who had charge of the patient ; and it is to be hoped that Dr. 
Laub will give a more circumstantial history. This man came in my charge 
as an invalid, in the last part of 1848, at N. Orleans barracks, and the main 
wound then presented nearly as follows : It had the appearance of having 
been made by two blows of a sabre, one passing somewhat obliquely downwards 
and inwards to the brain; the other slanting obliquely upwards and inwards, 
to unite with the first at an acute angle about two inches from the scalp. The 
surface of the brain, both above and below, was covered by a thick mem- 
brane ; a skinny membrane it may well be termed, through which the cerebral 
arteries could be felt pulsating, especially after the patient had been drinking 
too much whisky, which, unhappily for him, often happened. I lost sight 
of this man in one of his frolics; one day he drank too much, and ran away 
in the night, either in a state of delirium, or of mania-a-potu, and he has not 
been heard of since. 

Desperate wounds of the face, lower jaw, throat and neck, often recover, such 
is the vitality of these parts from the free distribution of nerves and blood-ves- 
sels, provided that no blood-vessel or nerve essential to life is injured. 

Case VI. — In the battle of Palo Alto, a private of the 8 th Infantry was 
wounded by a cannon-shot, which took off the greater part of the cheek, leaving 
only the deepest muscles. The man was not in my charge, but I saw the hor- 
rible wound on the field of battle. Several months afterwards I saw and ex- 
amined this man, and there was so little deformity that, to me, it seemed a 
surprising recovery. 

Case VII. — In a late number of the N. 0. Picayune, one of whose editors, 
Gr. W. Kendall, was an eye-witness of most of the leading battles in Mexico, 
is the following account : — 

" At the siege of Monterey, in 1846, and while General Worth's troops were ad- 
vancing to storm the small fort known as La Soldada, a man named Waters, an 
excellent soldier belonging to Captain Ben. McCuUoch's Ptangers, caaght a large 
grape shot directly in his mouth. It was fully the size of a hen's egg, was rough, 
uneven in shape, and in its course completely carried out the four upper teeth 
of the Ptanger, and part of the jaw, cut off the four lower teeth as with a chisel, 
split his tongue in twain, carried away his palate, went through to the back of 
his head, and, striking a tendon, glanced down and lodged under the skin on the 
shoulder-blade, Avhere it was extracted by a surgeon, and safely placed in the 
pocket of W aters for future reference. 

"No man thought the wounded Ranger could live; he could swallow neither 
food nor v/ater. We saw him two nights afterwards in a room in the Bishop's 
palace, which had been converted into a hospital, sitting bolt upright among 
the wounded and dying, for the nature of his terrible hurt was such that he 
could not lie down without suffocating. Ilis face was swollen to more than twice 
its natural size ; he was speechless, of course ; his wants were only made known 



1852.] 



Porter, Surgical Notes of the Mexican War. 



27 



by means of a piece of broken slate and pencil, and he was slowly applying a 
wet sponge to his mouth, endeavouring to extract moisture, which might quench 
the fever and intolerable tliirst under which he was suffering. By his side lay 
young Thomas, of Maryland, a member of the same company, who was mortally 
wounded the morning after, and who was now dying. Wounded men, struck 
that afternoon in Worth's advance upon the Grand Plaza, were constantly being 
brought in ; the surgeons were amputating and dressing the hurts of the crippled 
soldiers by a pale and sickly candle-light; and the groans of those in grievous 
pain added new horror to the scene, which was at best frightful. We recollect 
perfectly well a poor fellow, struck in both legs by a grape shot while advanc- 
ing up one of the streets. He was begging lustily, after one of his limbs had 
been amputated, that the other might be spared him,* on which to hobble through 
the world. Poor Thomas, as gallant a spirit as ever lived, finally breathed his 
last; we brought Waters afresh cup of water with which to moisten his wounds, 
and then left the room to catch an hour's sleep ; but the recollection of that 
terrible night will not soon be effaced from my memory. 

" The above incidents occurred on the night of the 23d, and morning of the 
24th of September, 1846. During the early part of the month of February fol- 
lowing, while passing into the old St. Charles, in this city, we were accosted 
with a strange voice by a fine-looking man, who looked extremely glad to see 
us, although he had a most singular and unaccountable mode of expressing him- 
self. We recollected the eye as one we had been familiar with, but the lower 
features of the face, although in no way disfigured, for the life of us we could 
not make out. 

" ' Why, don't you know me V in a mumbling, half-indistinct, and forced 
manner, said the man, still shaking our hand vigorously ; ' I'm Waters.' 

" And Waters it was, in reality, looking as well and as healthy as ever, and 
without showing the least outward sign that he had ever caught a grape shot 
in his mouth. A luxuriant growth of mustaches completely covered his upper 
lip, and concealed any scar the iron missile might have made ; an imperial on 
his under lip hid any appearance of a wound at that point; and, with the excep- 
tion of his speech, there was nothing to. show that he had ever received the 
slightest injury about the face. His tongue, which was terribly shattered, was 
still partially benumbed, rendering articulation both difficult and tiresome ; but 
he assured us that he was every day gaining more and more use of it, and in 
his own words he was soon to be just as good as new. 

" It is needless to say that we were truly rejoiced to see him ; to meet one we 
had never expected to encounter again in such excellent plight. Any one who 
could have seen him sitting in that apartment of the Bishop's palace, his face 
swollen, and with a gravity of countenance which would have been ludicrous, 
had it not been for his precarious situation and the heart-rending scenes around, 
would have been equally as much astonished and rejoiced as we were, on again 
so unexpectedly beholding him." 

The above is a graphic account of the state of the hospital at the Bishop's 
palace on that particular night, and is also a better description of the wounded 
man than would commonly be given by amateurs. 

Waters was wounded in storming La Soldada, on the 21st of September, by 
an escopette ball/j" which struck the right upper lip near the nostril, and beat 
out the teeth; then passed obliquely backwards and downwards to the left side, 
lacerating the tongue, and fracturing the left lower maxillary bone near the 
angle ; then coursed along the neck, and was finally extracted just above the 
clavicle, near the insertion of the sterno-cleido-mastoideus muscle. The upper 
lip was operated on exactly as for hare-lip; a smooth cut was made on each 
side of the wound, nearly in this shape, /\, and the edges were closely placed 
and kept in apposition by three interrupted sutures ; such teeth of the lower 

* Unfortunately it was spared; see Case XXIII., James Harvey. 
. t Escopette balls, 10 to the pound = 1.6 oz. each. 



28 



Porter, Surgical Notes of the Mexican War. 



[Jan. 



jaw as might become firmly implanted in their original position were carefully 
replaced; splinters of bone were removed, and the jaw brought to the upper 
maxillary bone, as to a splint, and bandaged in that position as closely as the 
nature of the injury would admit. Dangex was apprehended from intense in- 
flammation and swelling of the tongue, so as to prevent the passage of liquids 
and air; but this organ, fortunately, bears extensive injury without serious 
consequences. The patient was able to swallow a few drops of liquid, at first 
by means of the sponge, and afterwards a greater quantity from a small spoon. 
Danger was also apprehended from inflammation, suppuration, and constitu- 
tional irritation. Extensive abscesses, formed from the lower jaw to the 
clavicle, in the course of the ball, which were, at difi'erent times, laid open. 

November lOih. — Our general hospital broken up, the division to march to 
Saltillo, and Waters was sent to the other hospital in the following condition : 
G-eneral health good, so as to walk the streets for several days past ; wound of 
the lip healed admirably, presenting the appearance of having had the hare-lip 
operation performed when young ; head somewhat drawn down by the rigidity 
of the muscles; considerable rigidity of the parts around the lower jaw; and, 
of course, difficulty of articulation. 

Case YIII. — Sergeant-Major Brand, 5th U. S. Infantry, was wounded by 
a musket-shot, September 21st, in storming La Soldada, but he did not come 
under my care until after the wounded had been removed to the Casa Arista. 
The ball had passed into the right nostril, which was wide, taking with it a 
small portion of the upper lip; but the piece was so small that a stranger 
would not have noticed him among the wounded. The bullet passed above 
the palate, and lodged near the articulation of the jaw, between the coronoid 
process and masseter muscle. His report to me was that the surgeon in 
whose charge he came on the field, did not like to cut for the bullet, on 
account of the great number of nerves in the vicinity. Finding that the local 
irritation and the immobility of the jaw were io creasing, I determined to ope- 
rate. A deep cut, as small as ofifered a chance for extraction, was made at 
once down to the bullet, and although there was considerable hemorrhage, by 
plunging a narrow knife on each side of the ball at the ends of the incision, 
and then employing a blade of the artery forceps for a lever, the offending 
substance was removed. Some small pieces of bone were also extracted. 
The incision healed kindly, and he was sent to the permanent hospital on the 
10th of November, having immobility of the jaw, which would probably be, 
in some degree, permanent. 

Wounds of the Upper Extremiti/ . — Mr. Guthrie says : " An upper ex- 
tremity should not be amputated, for almost any accident or accidents that can 
reasonably happen to it from musket-shots.'^ 

Case IX. — Private Stephen Edwards, Company Gr, 4th Artillery, was 
wounded on the 22d September, at Monterey, by a musket ball, in the centre 
of the right shoulder, just below the head of the humerus. There was con- 
siderable hemorrhage, but it was determined to save the limb. Lint and 
compresses were applied to the wound, and as great a degree of pressure made 
as was prudent ; cold applications were also freely employed to the entire 
shoulder and upper part of the arm. If this did not control the bleeding, it 
was decided to amputate at the joint. At the next dressing, on the 24th, 
one object of which was to remove the compresses, which were saturated with 
blood, stiff, and unpleasant, there was a good deal of hemorrhage, and a simi- 
lar dressing was again applied ; and it was determined to postpone the next 



1852.] 



Porter^ Surgical Notes of the Mexican War. 



29 



dressing as long as possible. There was no more hemorrhage. Fever and 
inflammation came on, but the patient had a good constitution, went through 
it all well, and was sent to the permanent hospital, November 10, nearly 
recovered. I saw Edwards at Saltillo, in the month of December following, 
when he had a pretty good use of the arm and shoulder. 

Case X. — William Carley, Hays' Texan Kangers, was badly wounded, 
September 21st, at Monterey, by a musket ball, which passed through the 
right shoulder a little below the joint, and made its exit just below and near 
the centre of the clavicle, on a line with the axilla. Amputation at the 
shoulder-joint ought to have been performed, but the patient refused. He 
finally escaped with his life, but the limb was useless. Sent to the permanent 
hospital, November 10th. In 1847 this patient was heard from, and the 
limb was reported as dangling uselessly by the side. 

Case XI. — Private Mark Collins, A, 3d Artillery, was severely wounded 
in the right hand, at Monterey, on the 22d of September, by a musket ball, 
which passed through every metacarpal bone, from right to left, the hand in 
the prone position, and through the joint and first phalanx of the thumb; 
severe inflammation came on, and afterwards free suppuration and congestion 
of the superficial vessels. At first, cold water and solution of acetate of lead 
were freely used, and afterwards poultices and free incisions. Several splinters 
of bones were removed in the progress of the case. Notwithstanding the 
severity of the wound, his general health remained good, and the hand was 
pretty well recovered when sent to the permanent hospital, November 10th. 

Case XII. — Private Oliver Jenkins, Hays' Rangers, was severely wound- 
ed, at Monterey, on the 21st September, in the right hand, by a musket ball, 
which passed through every metacarpal bone. This case so nearly resembles 
the above, and the treatment was so similar, that little more need be said. 
Free incisions were necessary for the discharge of pus, and to relieve the 
loaded vessels, as in the above case, and several pieces of bone were taken 
away. Turned over to the permanent hospital on the 10th of November. 

Penetrating gunshot wounds of the chest are always dangerous. 

Case XIII. — Private Johnson, J, 4th Artillery, was wounded at Eesaca 
de la Palma, by a musket ball which struck the right side of the chest on the 
sixth rib. No trace of the ball could be found by a hasty examination on the 
field of battle, but it was evident that the lung was not injured, the breathing 
being free, no cough, and no bloody expectoration. The ball was afterwards 
found and extracted at Point Isabel, and the man recovered. 

Case XIV. — Private Rieniecke, A., od Artillery, was wounded at Monte- 
rey, early on the morning of the 22d September, in storming the hill called 
Loma de Independeucia. The wound was made by a buckshot through the 
right scapula, about two inches above the inferior angle, and penetrated the 
lung. Rieniecke always contended that the wound was made by our own 
men in the rear, and his opinion was doubtless correct. The storming took 
place under cover of Egyptian darkness ; the shot was received in the back 
while advancing ; and it was evidently a buckshot wound, and the Mexicans 
did not use buckshot. For some time the symptoms were severe, but he 
finally nearly recovered, and was sent to the permanent hospital on the 10th 
November. 

This case recovered simply because the buckshot did not lacerate the lung, 
as a musket ball would have done. There were other gunshot wounds of the 
lungs in the three days of Monterey, made by musket balls, which terminated 
No. XLY.— Jan., 1852. 3 



30 



Porter, Surgical Notes of the Mexican War. 



[Jan. 



fatally. The Mexican musket bullet is large, weighing not much less than an 
ounce, and the wound to a vital organ from it may be considered almost cer- 
tainly fatal. 

Gunshot wounds of the abdomen are always fatal. Recoveries may take 
place, and desperate cases of this kind have recovered, but they are exceptions 
to the rule. 

Case XV, — Artificer Nidy, I, 4th Artillery, received a musket shot in the 
abdomen at Resaca de la Palma. The ball entered one inch to the right of 
the umbilicus, and as there was no mark of exit, it was presumed to be lodged 
in the abdominal cavity. He never recovered from the shock, and died the 
same night. 

Case XYI. — Private Boyd, J, 4th Artillery, in storming the Loma de In- 
dependencia on the 22d September, received a wound from a musket ball 
between the eleventh and twelfth left ribs, on a line with the anterior supe- 
rior spinous process of the ilium. The ball passed out on the back, a little 
to the left of the spinal column. He lingered several days, and died on the 
9 th of October. Only slight cases of this class are expected to recover. 

Wounds of the pelvis, and parts adjacent, are exceedingly dangerous. 

Case XVII. — Herman S. Thomas, of Maryland, was wounded by an esco- 
pette ball, in storming the Loma de Independencia, on the 22d September. 
The ball passed through the left hip, entering just above and behind the ante- 
rior inferior spinous process of the ilium, and passing out on the inner side of 
the thigh, below the lesser trochanter. Died on the 24th. 

Case XVIII. — Corporal Mark Morrow, Mackall's battery, was wounded 
by a grapeshot at the storming of Monterey, on the 23d of September. The 
shot struck the upper part of the thigh and inguinal region, external to the 
large artery. There was no mark of exit. He was brought into hospital late 
at night, and on examination the wound appeared exactly like having been 
made by the brush of a ball passing by, and just touching the integuments 
and cellular membrane ; and what added to this impression was, that there 
were no constitutional symptoms, and the patient actually walked, voluntarily, 
several steps, to the bed provided for him. He was, therefore, kept quiet; 
the wound was superficially dressed; the bowels regulated; he was put on a 
mild diet, which was relished; no thirst; pulse and respiration natural; he 
was cheerful and lively, noticing common occurrences ; and altogether, he was 
considered in a fair condition for recovery for several days. This state of 
things continued until the 30th of September, and the opinion was strongly 
formed that the injury was superficial, and that the patient would recover; 
but constitutional irritation commenced, the pulse became frequent, loss of 
appetite, thirst, coated tongue, and wandering of the mind, ending in delirium, 
all came on, and death took place on the 7th of October. It will be seen that 
no attempt to operate was made, for the following reasons : — If the shot were 
superficial, no operation was necessary; if perpendicular, all attempts to operate 
would have been useless. Autopsy. — The head of the femur was shattered 
into several pieces, and the acetabulum was shattered in all directions and 
driven in; the grapeshot was found imbedded in the glutei muscles. 

Gunshot wounds of the lower extremity are much more serious than those 
of the superior. Wounds of the foot and leg do do not, by any means, re- 



1852.] 



Porter, Surgical Notes of the Mexican War. 



31 



cover so readily or so perfectly as wounds of the hand and forearm, and gun- 
shot wounds of the upper third of the femur are among the most terrible that 
can be inflicted. 

Case XIX. — A Mexican officer was wounded and taken prisoner at Mon- 
terey; the shot, a musket ball, struck the right tarsus, passing through so as 
to injure both the middle and external cuneiform bones. This wound did not 
do well, but rather grew worse from day to day, so long as the patient re- 
mained in our hospital, which was but a short time. The limb was ampu- 
tated in the Mexican hospital, and I afterwards understood that the patient 
did not recover. 

Case XX. — Private Buzby, K, second artillery, was wounded at Monterey, 
on the 23d of September, by a musket ball which struck the left leg below 
the belly of the gastrocnemius muscle, passing between the muscle and the 
tibia, and making its exit on the outside of the limb, near the fibula. Neither 
the tibia nor fibula were injured, yet the patient was confined by the wound 
a long time, and was finally sent to the permanent hospital, on the breaking 
up of ours, November 10th. 

Case XXI. — Private McKnight, I, eighth infantry, received a musket ball 
through the thickest part of the gastrocnemius muscle, at Monterey, on the 
23d of September. No injury to the bone. This man was also confined a 
long time. Sent to the regimental hospital, November 10th. 

Case XXIT. — Private Morton, Louisiana volunteers, was wounded in the 
right leg, at Monterey, on the 22d of September, by a musket ball which 
struck the front of the right leg, about three inches above the ankle-joint, in- 
juring the tibia, though it was not fractured. This was a painful and trouble- 
blesome wound; inflammation, suppuration, intense pain, and irritative fever 
supervened, the pain being so severe as to require the free use of anodynes; 
and, in consideration of all the circumstances, it might have been advisable, 
perhaps, to amputate the limb. He finally recovered so far as to be sent to 
the permanent hospital, November 10th. 

Case XXIII. — Private James Harvey, H, fourth artillery, was wounded 
at Monterey, on the evening of the 23d of September, by a cannot shot in 
both legs. The right leg was badly shattered and lacerated, and the left tibia 
was comminuted, though the integuments were not broken. Both legs were 
injured about two inches above the ankle. It was plain that both limbs ought 
to come off, but the patient was a cross-grained Irishman, and we had much 
difficulty to get his consent for the operation on the right leg; but when it 
came to the left, he positively refused to lose it, swore he would die first, &c. ; 
and he was finally disposed of, about 11 o'clock, P. M., as comfortably as cir- 
cumstances would permit. Next morning, and so long as there was a chance 
of success, he positively refused to lose the leg. One afternoon he sent for 
me, said he would lose the limb, and begged me to operate — it was too late. 
Mortification of the limb had taken place ; and he had frequent and feeble 
pulse; dusky complexion; acrid heat of the skin; brown tongue; and when 
there was nothing particularly to excite his attention, the mind wandered. 
He would have been lost in the operation. He died before morning, Septem- 
ber 28th. The dressings on the right had not been touched, and on their 
removal post-mortem, the operation was found entirely successful. The inci- 
sions had healed soundly and perfectly, excepting at the point of the ligatures, 
and the stump was a beautiful one. I have since regretted that force had not 
been used and both limbs amputated, for it was certainly justifiable in this 
case, if ever. Operation by the circular incision. 



32 Porter, Surgical Notes of the 3Iexican War. [Jan. 



Case XXIY. — Sergeant Wallender, Duncan's battery, was wounded in the 
upper portion of the left leg, at Palo Alto, May 8th, 1846. Amputation 
was performed on the field, at the usual point above the knee, by the circular 
incision. On the next day he was sent to the hospital at Point Isabel, 
where he recovered. The points of interest in this case are two : The first 
is, that being an ingenious mechanic himself, he has made an artificial limb, 
which is so useful that he is able to walk the streets without much apparent 
lameness; and he has procured a patent, I understand, for his invention, and 
gone into the business of manufacturing artificial limbs in one of our large 
cities. The next interesting point is in comparison with the following case. 

Case XXV. — Artificer Cones, Duncan's battery, was wounded by a can- 
not shot at Palo Alto, in the right leg, the tibia being shattered from near 
the ankle-joint three or four inches upwards, but the integuments were not 
lacerated. Amputation below the tubercle of the tibia ought unquestionably 
to have been performed in this instance; but the man insisted, against all 
reason, on running the risk, and the operation was reluctantly given up. It 
was bad practice, for which the surgeon was not responsible. Cones was sent 
to Point Isabel at the same time with Serjeant Wallender, and there he barely 
escaped with his life, passing through inflammation, suppuration, extraction of 
pieces of bone, constitutional irritation, &c. ; and so late as January 1847, he 
had the appearance of a person in general ill-health, the limb still being trou- 
blesome. At this time, he may have a less troublesome and more serviceable 
limb than "Wallender, but even this may be somewhat doubtful. 

Case XXVI. — Private William Williamson, Company K, first dragoons, 
was admitted into the general hospital at Vera Cruz, in September 1847, for 
a gunshot wound of the right leg, which required amputation. The discovery 
of Dr. Wells, that certain gases and vapours might be inhaled and produce 
insensibility to pain, had been brought before the profession, and just at this 
time sulphuric ether was the fashionable agent for inducing anaesthesia. It 
was employed in this case, having been used several times previously in the 
same hospital. The operation was well performed by one of my assistants, the 
arteries being taken up by myself. The efi'ect of this aetherization was un- 
favourable — it was decidedly pernicious. Emesis and hsemoptysis were brought 
on; there was paleness of the face, approaching lividness; and a slow and 
feeble pulse. Plenty of fresh air was brought into circulation, and cold water 
was dashed upon the face. These remedies were applied as soon as the bones 
were sawed through ; and as soon as the patient could swallow, without risk 
of suffocation, brandy and water was administered. The limb was dressed as 
soon as practicable, and in a few hours the face resumed its natural colour ; 
the stump was a good one, and it was well dressed, the incisions being placed 
in exact apposition. But the operation was not successful, nor was this sur- 
prising. On making the incisions, during the operation, dark, venous-looking 
blood flowed, as might have been expected; but on permitting the blood to 
flow from the main arteries on tying them, it resembled venous much more 
than arterial blood. Large dark coagula were sponged from the stump 
after the arteries were secured, and the muscles were of a darker hue than 
usual. At the first dressing, not a vestige of union by the first intention 
could be seen, and the result was, that the wound remained open. The mus- 
cles gradually regained their healthy tone and colour, and granulations began 
to spring up around and between the bones; and it was -then found, that 
the flaps (it was a flap operation) were not sufficient to cover the projecting 
bones. In about three weeks, a second operation was performed, and the 
bones sawed so that the flaps would be sufficient to make a decent stump. 



1852.] 



Porter, Surgical Notes of the 3Iexican War. 



33 



He finally recovered; was discharged service March 3, 1848, at Yera Cruz, 
Mexico ; and was admitted into the hospital at New Orleans barracks, March 
15, 1848, as an invalid. There is no further record of him in my possession. 

In this case the blood was poisoned, and the muscular contractility destroyed ; 
hence the soft parts were found insufficient to cover the bone, after the patient 
had recovered from the deleterious efi"ects of the ether. The patient may have 
been overdosed, or what is more probable, the ether may have been respired 
in too concentrated a state instead of being freely diluted with atmospheric air, 
the administration in this instance having been made with a very scientific 
apparatus, by a professor of the art, instead of using plain sponge or a common 
handkerchief. Grunshot wounds were not very successfully treated at Yera 
Cruz, in the summer of 1847; the air was bad, and the city unhealthy; but I 
have often thought that the effect of the inhalation of ether, in those cases in 
which it was employed, was as injurious as any other malign influence what- 
ever. We had occasion to perform many operrations at Yera Cruz, in 1847, 
and our experience with sulphuric ether was sufficient; and, I do not hesitate 
to say, that my conclusions were opposed to its further employment. By the 
inhalation of ether, in the most cautious manner, in sufficient quantity to pro- 
duce insensibility to pain, the blood is poisoned, the nervous influence and 
muscular contractility is destroyed or diminished, and the wound is put in an 
unfavourable state for recovery. It may be said that Williamson was over- 
dosed. Granted. But, I repeat, I have never seen ether administered pre- 
vious to an operation, however cautiously, without producing, in my humble 
opinion, more or less unfavourable symptoms ; symptoms of poisoning of the 
blood; and, at the close of the war, I had determined never to use it again. 
In truth, its use was abandoned in our hospitals at Yera Cruz some time before 
the treaty of peace was signed. We had no experience with chloric ether, 
chloroform, &c., in Mexico. Luckily, we do not need the chloroform bottle 
on the field of battle. In obstetricy, chloroform can be but seldom necessary ; 
and in natural labour one might as well think of resorting to the Csesariau sec- 
tion to facilitate delivery, as to employ chloroform. In unnatural labour, or 
in instrumental delivery, chloroform may be advisable ; for of two evils we 
must choose the least, and this is the case in all surgery. 

Case XXYII. — G-ilbert R. Brush, Hays' Rangers, was severely wounded 
in the left knee, at Monterey, September 22d, by a musket ball, which passed 
obliquely through the patella, fracturing it, and came out on the inside of the 
joint. Considerable inflammation ensued, which subsided with moderate sup- 
puration ; and great care was taken to keep the pieces of the broken patella 
in place immediately on the subsidence of the inflammation. Discharged ser- 
vice, November 2d. I met Brush at Yera Cruz, in the autumn of 1847, in a 
mounted company of Texans; his leg was quite well and useful; no stifl"ness 
of the joint ; and but little deformity. He assured me that while the war 
lasted I should always have his custom.'' 

Case XXYIH. — Private Dennis Kelly, Company A, 8d Artillery, was 
wounded at Monterey, 22d of September, by a musket ball which passed 



34 



Porter, Surgical Notes of the Mexican War. 



[Jan. 



tlirough the right triceps adductor femoris, near the femur, immediately above 
a line dividing the thigh into two portions, upper and lower. Neither the 
bone nor the large bloodvessels were injured. This case went on well for 
several days, but little inflammatiou supervened, and there seemed to be no 
reason why the man should not do well. But he was not young (he was pro- 
bably forty-five or fifty years of age), he had had dysentery since leaving 
Matamoras, and his constitution was broken. The wound itself never ap- 
peared badly, but the patient's strength gradually failed, the skin and eyes 
became yellow, and he sunk. Died, October 16th. 

Case XXIX. — B. F. Keese, Hays' Rangers, was wounded at Monterey, 
September 21st, in both thighs, by a musket ball. The wound in the left 
thigh was superficial, the ball passing through the inner part ) the ball passed 
through the mass of muscles of the right thigh, nearly midway between the 
hip and knee, without touching the bone. Neither wound was considered 
dangerous, and both always appeared to be doing well ; but his constitution 
was weak, and he gradually sunk, without any other sign of disease than de- 
bility. Died, October 16th. 

Case XXX. — Corporal Oakley, K, 8th Infantry, was wounded at Monterey, 
September 21st, by a musket ball which passed through the scrotum, and then 
through the inner part of the left thigh, from right to left. This wound did 
well, and the patient recovered. Oakley was sent to his regiment on the 2d 
of November, being, as he said himself, as good a man as he ever was.^'* 

Case XXXI. — G-eorge Evans, Company A, La. Vol. Battalion, twenty-four 
years of age, was admitted into the general hospital at Vera Cruz, in the after- 
noon of August 3d, 1847. He had received a terrible gunshot wound from 
a musket ball, which entered above the right trochanter major and passed 
obliquely downwards, fracturing the neck of the femur, and had then passed 
out just above the lesser trochanter ; the ball then entered the scrotum, and 
finally made its exit on the left side of the penis. On entering the hospital, 
brandy and water was administered in consequence of the debility produced by 
loss of blood and the shock to the nervous system. After ' serious considera- 
tion, it was determined not to amputate at the hip-joint, but to attempt to save 
the man's life and limb together. Some small pieces of bone were extracted, 
the wound dressed, and sol. plumbi acet. directed, to be discontinued if it 
should produce chilly sensation. A catheter was introduced into the bladder, 
fears being entertained that subsequent inflammation would obstruct the flow 
of urine, and that the urethra was injured. R. — Morphia sulph. gr. ss. hora 
somni. 

August 4th. Inflammation increasing ; fever. R. — 01. ricini ^j. Continue 
sol. plumb, acet. freely. Beduce the morph. sulph. to one-quarter gr. at night. 

bth. Inflammation much as yesterday; fever less. Continue the applica- 
tion. E^emoved the catheter entirely ; urine flowed freely during the day, and 
afterwards. Morph. sulph. at night. 

* Remarkable escapes of the genital organs from gunshot wounds sometimes occur. 
Some years ago (1840), a man was shot, in Florida, by the Seminole Indians. The bullet 
went through the mass of muscles on the upper and back part of the right femur, through 
the septum scroti in its length, and kept on in the course of the penis, from which it 
finally made its exit, near the glans on the left side. The urethra was not at all injured, 
for he always urinated without dilTiculty ; neither was either testicle hurt; and the man 
recovered with but little deformity, the organ being as useful as before the wound was 
received. It is to be recollected that the size of the Seminole bullet is much less than 
thatof the Mexican musket ball. 



1851.] 



Porter, Surgical Notes of the Mexican War. 



35 



6th. But little fever; inflammation not so great in the vicinity of the wound. 
Poultices were applied, and wine and generous diet ordered. Morph. sulph. 
at nigbt. 

7th. Suppuration commenced, and some small pieces of bone were removed. 
But little fever and less inflammation. Continue poultices, wine, and diet. 

^th. Rested badly last night; fever; bowels somewhat constipated. R. — 
Mas. hydrarg. quin. sulph. aa. grs. x. In four hours after, ol. ricini ^ss. P. 
Dover, grs. x. at night. Continue the poultices. Omit the wine. 

dth. llested well, no fever. Quin. grs. v, ler in die. The poultices were 
continued. Wine resumed. 

10th. llested well, same treatment. 

llth. From this date the patient improved; generous diet, wine and malt 
liquors were prescribed, and the suppuration gradually diminished. The pa- 
tient was placed on his back and long splints were applied, moderate extension 
and counter-extension being employed. During the progress of the case the 
patient suffered from attacks of diarrhoea, and he had also two or three attacks 
of intermittent fever. Finally, he recovered so as to be discharged from ser- 
vice on the 15th of January, 1848. At the time of discharge the limb was 
shortened about two and a half inches. The above is a brief history of the 
case, the limits of this paper having already been transcended. 

"When Evans was admitted into hospital, the following important questions 
presented: Shall the limb be amputated at the hip-joint? or shall the limb be 
saved ? "Which will give the best chance for life ? The course is already 
seen. Hennen says: — 

"Simple and safe as the operation of amputation is, at the articulation of the 
upper extremities with the trunk, it becomes one of the most serious in military 
surgery, when the lower are engaged. There is not one patient in a thousand 
that would not prefer instant death to the attempt. Obliged as we are, coolly, 
to form our calculations in human blood, there is still something in the idea of 
removing the quarter of a man, at which the boldest mind naturally recoils ; 
and yet there are cases, in which we have it only left to balance between certain 
death and this tremendous alternative!" 

Mr. Guthrie uses the following language : "I approach the subject of com- 
pound and gunshot fractures of the thigh with greater diffidence than I do any 
other in surgery, not from want of experience, or, I trust, of observation on 
that experience, without which it is of no value, but from the unfortunate 
nature of the results.^' * -x- ->;■ -k- " Of these, the fractures of the first kind 
(head and neck of the bone in the capsular ligament from gunshot) are, I be- 
lieve, always ultimately fatal, although life may be prolonged for some time.^' 
Mr. Guthrie says further: "When the head or neck of the femur have been 
injured by musket balls, the patient has never escaped with life to my know- 
ledge, unless after amputation. He does not die, however, immediately, but 
lingers for two, three, or even more months, and at last sinks worn out by suf- 
fering.^' * -H- -ss- * " You ought not to be allowed to take out a limb at the 
hip-joint, unless the head and neck of the thigh-bones are injured; and you 
ought not to take it out if they are, unless the shaft of the thigh-bone is irre- 
parably implicated also."* 

The result of the foregoing case was satisfactory indeed, for the patient's 
life was preserved. Surgeon P. H. Craig, Medical Director of General Tay- 

* It is proper to state that the last quotation is from Mr. Guthrie's lecture on the ex- 
cision of the head of the thigh-bone. 



36 VoriQ,r, Surgical Notes of the 3Iexican War. [Jan. 



lor's army, mentioned to me a similar case on the line of the Rio Grande, after 
our division was put en route to Vera Cruz, and the life of the patient was saved. 

Amputation. — The flap operation has been fashionable for a number of 
years ; it has numerous and talented advocates ; while little has been said, 
comparatively, in favour of the circular mode of operating, here and there an 
instance excepted. But the flap operation has disadvantages, especially in 
military surgery; and the circular has advantages; so that, all things con- 
sidered, it may well be questioned if the latter is not the preferable one. 

The wound made in the formation of flaps is more extensive than that by 
the circular operation. This is a matter of more importance, perhaps, than 
may at first sight appear. Even if the wound be certain to heal by the first 
intention, the objection has force; but if the wound should not heal by the 
first intention, there is an immense gaping wound — an ulcer, if the patient 
live long enough — to which the unhealed circular incisions bear but limited 
proportion. Suppose we are compelled to form a large military hospital in an 
unhealthy position, or country; that the hospital should be crowded with 
wounded ; or that, from any cause, there should be a bad atmosphere ; the 
wounds must heal badly, or with uncertainty, and the extensive incisions for 
flaps ought, if possible, to be avoided. 

Sennen's Militar}/ Surgery^ pp. 176-184, 196-200. Guthrie's Clinical 
Lectures, p. 70. 

It is a great desideratum in surgery, both civil and military, to bring the 
edges of the opposing flaps (whether the operation be really flap, or circular) 
into exact apposition, and to keep them so. Especially is this of the utmost 
importance in military surgery, on the field of battle, where the wounded must 
always be ready for removal as soon as practicable, and a sufficient number of 
stitches to effect this must be had recourse to. 

The extent of the wound made by the operation must, therefore, have con- 
siderable influence on the comfort, health, and life of the patient ; and in this 
respect, the circular operation is to be decidedly preferred. 

It is claimed by the advocates of the flap operation, that it can be sooner 
done than the circular. Even if this were certain, the old maxim — citus sat, 
si sat bene — must be recollected. Mr. Guthrie uses the following language : — 

"I have told you that seventy to eighty seconds is enough of time for cutting 
off a thigh ; but then you must know how to do it. Sixteen seconds gain of 
time to you in sawing a bone, maybe sixteen months of misery to your patient; 
let time therefore be a secondary consideration." 

The flaps may be sooner made than the circular cuts, but the bone cannot 
be so readily or so well sawed through, owing, to the acute angle at the point 
of union. 

But the difficulty of securing the obliquely cut arteries in the flap opera- 
tion, and the additional time required for dressing the stump, fully counter- 
balance the rapidity of the operation in the first stage. 



1852.] 



Porter^ Surgical Notes of the Mexican War. 



37 



A Mexican soldier was wounded by a cannon shot at Palo Alto, and the 
thigh amputated on the field the morning after^ by the medical director of 
our army, Surgeon P. H. Craig, by the flap operation. I assisted Dr. Craig, 
and there was so much difficulty in securing the obliquely divided artefies, 
that we both came to the conclusion it was not a proper operation for 
the field. 

The future stump is a most important consideration. Will the stump 
formed by flaps, or by circular incisions, prove the best and most useful ? 

At Monterey I amputated the arm of a wounded Mexican soldier, on the 
morning of the 23d September, just below the insertion of the deltoid muscle, 
by the circular incisions, and soon after the man was sent to his own hospital. 
I met him afterwards at Saltillo, in the month of December, perfectly reco- 
vered, and a better stump was never seen. He was making bis way to his 
own army at San Luis Potosi, in the best manner he could, and I gave him 
a little money to assist him on his journey. He told me that their wounded 
men receive no pensions from Government, as in our service, but had to sub- 
sist in the best way they could. 

Case XXIY. — Sergeant Wallender may be referred to; see also Case 
XXIII, James Harvey, a circular operation, the cicatrix perpendicular, patient 
reclining on the back. My limits will not allow of more cases. I cannot 
refrain, however, from the following quotation :— 

The comfort and usefulness of one who has suffered amputation, and is 
relying on an artificial limb, will depend much upon the manner of the opera- 
tion. A good, conical-shaped stump, with a solid and well-adjusted covering 
over the end, is always desirable. Too often in the flap operations, the cover- 
ing is either made too large, so that when the wound is healed, a loose, pendu- 
lous mass hangs from the posterior portion of the stump, or it is made so small 
as not to cover sufficiently the end of the bone, to prevent its protrusion ; in 
either case causing great inconvenience to the patient, in attempting to wear 
an artificial limb.^' 

" The objection which has been raised against the circular operation, to wit, 
'that it produces a conical-shaped stump, unfavourable to the adjustment and 
use of an artificial limb,^ so far as it is founded in fact, is the very strongest 
argument in favour of that manner of operation. A conical-shaped stump, 
whether long or short, with a solid, well-adjusted flap, covering the end, is 
always highly favourable for the application and use of an artificial limb." — 
(E. D. Hudson, M. D., on Artificial Leg—iV. Y. Med. Jour., Nov. 1850, p. 429.) 

From the foregoing remarks it will be perceived that, in almost every 
instance of amputation of the extremities, the circular operation is to be pre- 
ferred. The exceptions will be stated hereafter. 



38 



Pepper, Cases of Empyema. 



[Jan. 



Art. II. — Cases of Umpi/ema, with Remarks, especially in reference to Para- 
centesis. — By Wm. Pepper, M. D., one of the Physicians of the Pennsyl- 
vania Hospital. 

Case I. — A boatman, aged about forty-five years, came under my care in 
January 1844; he stated that during the spring of 1842, he had suffered 
with severe pain of the right side, followed by the usual symptoms of acute 
pleurisy. For the following two years and a-half he continued to suffer with 
more or less difficulty of breathing, slight cough, and emaciation, but was still 
enabled to support himself by vending oysters about the streets. About the 
middle of December 1844, he was suddenly seized with severe pain in the 
right axillary region, followed by excessive dyspnoea and total inability to re- 
main in the horizontal position; on the 27th of the following month he entered 
the hospital, and then presented the following symptoms : Constant hectic 
fever, with considerable oppression, slight cough, and mucous expectoration; 
he reclined constantly upon his right side, and could not be induced to change 
his position. This side of the chest was distended, exceeding the left in cir- 
cumference by about one inch, and the lower intercostal spaces were somewhat 
bulging ; excepting at the summit of the lung no vesicular murmur could be 
detected; in the axillary region, however, the respiration was amphoric, and 
occasionally attended with metallic tinkling; in front the voice also had a pe- 
culiar metallic resonance. The percussion over the back and side was perfectly 
flat, whilst in front and near the nipple it was decidedly tympanitic; the line 
of dulness could, however, be varied by changing the position of the patient; 
succussion also elicited the peculiar gurgling or splashing sound indicative of 
the presence of liquid and gas in the thoracic cavity. 

The patient remained in much the same condition up to March 1st, when 
it was evident that his dyspncea had greatly increased; in addition to the 
above-mentioned physical signs, the heart was dislocated and could be felt 
pulsating beyond the left nipple, the liver also projected low down into the 
abdominal cavity. The expectoration had now become slightly puriform, and 
the respirations were about thirty-five to the minute, and entirely confined 
to the left side; at the same time the emaciation and prostration had percep- 
tibly increased; but what was most worthy of observation were the crackling 
rales, prolonged expiration, and dulness of percussion, now detected under the 
right clavicle. 

No important change, excepting the gradual failure of the powers of life, 
occurred up to the time of his death, which took place April .2d, or about two 
months after he first came under my care. The chief treatment pursued in 
this case, consisted in the administration of iodide of potassium, syrup of 
seneka combined with carbonate of ammonia, counter-irritation over the chest, 
and a nutritious diet. 

The body was examined the following day. On puncturing the front of 
the right thorax there was an escape of gas sufficient to extinguish a candle 
held several inches from the orifice ; a small trocar was then introduced be- 
tween the seventh and eighth ribs near their angles, and was immediately fol- 
lowed by a gush of thick greenish pus. Upon opening the cavity of the 
thorax, the right lung was found compressed against the spine, and not more 
than an inch in thickness. The apex contained numerous small tubercles, 
and in that portion of the lung which corresponded with the mammary region, 



1852.] 



Pepper, Cases of Empyema. 



39 



there was a perforation about the eighth of an inch in diameter, communi- 
cating with a small cavity, evidently the result of softened tubercle. The 
summit of the lung was adherent, but the rest of this organ, though com- 
pressed and coated by a thick layer of soft lymph, was not firmly attached to 
the posterior mediastinum. The right pleura contained at least one gallon of 
pus, but the ribs were not necrosed, as often happens under similar circum- 
stances. The left lung contained a few disseminated tubercles. 

In the above case, it would appear that the acute pleurisy contracted in the 
spring of 1842, was, from neglect or inefficient treatment, allowed to degene- 
rate into chronic empyema ; and it is highly probable that the tubercular per- 
foration, followed by pneumothorax, occurred in December of 1844, at which 
time the patient complained of sudden and severe pain in the axillary region. 
The crude condition of the tubercles, as ascertained after death, renders it not 
unlikely that their development was consequent upon the pleurisy, and the 
direct result of a vitiated condition of the system induced by chronic irrita- 
tion or purulent absorption. When the patient first came under my notice, 
the physical signs clearly indicated a fistulous opening into the lung; soon 
after this, the crackling and prolonged expiration under the clavicle induced 
the belief that the empyema was also complicated with tubercular deposit, and 
that, therefore, under these circumstances, but little was to be hoped for from 
paracentesis. At an earlier period, however, it is by no means improbable 
that this operation might have prolonged life, or even effected a permanent 
cure. 

Case 11. — June 7th, 1850, a young woman, aged twenty-three years, en- 
tered the hospital, suffering with considerable oppression and some cough. 
She stated that about eleven weeks before, she had been seized with severe 
pain in the right side, followed by fever, slight cough, and oppression; no 
treatment, however, had been pursued in her case up to the time of admission. 
She was now emaciated, but had no fever, though her pulse was frequent and 
feeble; the cough also was but little and entirely unattended by expectoration. 
The most marked symptom, however, was the excessive dyspnoea; and this 
was greatly increased by the slightest exertion. The right side was evidently 
distended, and exceeded the left by nearly two inches in circumference; 
throughout this side the percussion was perfectly flat, and no vesicular mur- 
mur could be heard over any part of the lung ; along the spine, however, and 
particularly at the root of the lung, the respiration was loud and bronchial, 
whilst over the greater part of the left lung it was more or.less masked by large 
mucous rales. The liver could be felt depressed below the margin of the false 
ribs, and the pulsations of the heart were visible beyond the left breast. A 
blister was applied over the diseased side, whilst calomel, squill, and digitalis 
were administered in connection w^ith an occasional dose of senega and carbon- 
ate of ammonia. The above remedies could not, however, be perseveringly 
used, owing to the great irritability of the alimentary canal. 

By the 14th, or one week after admission, the prostration had so far in- 
creased as to demand the use of stimulants, such as milk-punch, carbonate of 
ammonia, and Hoffman's anodyne; at the same time, the difficulty of breath- 
ing had become very distressing, and attended with blueness of the hands and 
lips, and coldness of the extremities. The patient was now in a more or less 



40 



Pepper, Cases of Empyema. 



[Jan. 



lethargic condition, and quite indifferent as to the ultimate result of her dis- 
ease; and it was quite apparent, that unless relieved by surgical means, life 
must soon become extinct. In consultation, however, the operation of paracen- 
tesis was deemed inexpedient on account of the excessive prostration ; the 
most powerful stimulants were now freely administered in the hope of rallying 
her strength, but in despite of these means she gradually sank and expired on 
the 18th, or about ten days after her admission into the hospital. 

On examining the body the following day, the right pleura was found to 
contain two ordinary wash-basins full of serum, and the lung was coated by a 
thick layer of soft lymph, and closely compressed upon the spine by the su- 
perincumbent fluid ; the mediastinum was forced far to the left side, and the 
liver was much engorged and greatly depressed. The right lung when incised 
closely resembled macerated flesh, and in its central portion there was appa- 
rently a small patch of inflammation ; the left lung was perfectly healthy, as 
were the other organs. 

The absence of hectic fever and purulent expectoration, in connection with 
the fact that the intercostal spaces were not bulging, or the superficial veins 
distended, led to the belief that the effusion was serum and not pus; and 
judging from the previous history of the case, there was no reason to suspect 
tubercular complication. The examination, post-mortem^ confirmed these views, 
and strengthened me in the opinion, that if the operation had been performed 
even at the late period at which it was proposed, the patient might have been 
rescued from impending death: the mere fact that the lung was, in a great 
measure solidified and coated with lymph, cannot be considered as conclusive 
evidence of the utter impracticability of its ever having regained its natural 
condition, even had the compressing fluid been removed, for there is good 
reason to believe that, in many instances of a similar character, the lung has 
gradually unfolded as absorption progressed, and finally resumed its normal 
position and function. 

Case III. — A stone-cutter, aged about thirty years, came under my care 
in April 1850. He stated that about four months previous he had suffered 
with severe pleurisy of the right side, for which, however, he had been sub- 
jected to no kind of treatment; his previous health had been good, nor was 
there any hereditary tendency to pulmonary disease. When I first saw him 
he was emaciated and suffering with hectic fever; he also had slight cough 
and puriform expectoration with laborious breathing. The right thorax was 
distended, and the lower intercostal spaces bulging; over this side no vesicular 
respiration could be heard, but at the angle of the scapula there was loud 
amphoric respiration and resonance of the voice; when the patient was on his 
back, the percussion over the entire front of the right side was perfectly tym- 
panitic, wiiereas when he assumed the sitting posture it became flat from 
above the nipple down to the margin of the ribs; moreover, a distinct splash- 
ing sound could be heard during the act of coughing. The heart was forced 
to the left, and the liver depressed, as is usual in case of extensive effusion of 
air or liquid into the cavity of the right pleura ; the respiration throughout 
the loft lung was puerile and evidently supplementary, but at the same time, 
more or less masked by loud, sonorous, and sibilant rales. 

Squill and senega, combined with carbonate of ammonia, were given in con- 



1852.] 



Pepper; Cases of Empijema. 



41 



nection witli various tonics, without, however, affording any relief to his dis- 
tressing symptoms. On the 16th of May, or about three weeks after my 
first visit, the percussion had become quite dull over the front of the right 
thorax, excepting, indeed, about a hand's-breadth under the clavicle wliere it 
still remained tympanitic; at the same time, there was slight swelling of the 
intercostal space between the sixth and seventh ribs, and the superficial veins 
in this region were considerably engorged. As it was evident that the effusion 
into the cavity of the chest had greatly increased within the last few days, 
and that the death of the patient was inevitable unless promptly relieved, I 
was induced to make a deep puncture with an ordinary thumb-lancet into the 
intercostal space between the sixth and seventh ribs, and about midway be- 
tween the spine and sternum, corresponding with that part of the swelling 
where there was some evidence of deep-seated fluctuation. But a few drops 
of pus followed this procedure, and it was not until a moderate-sized canula, 
armed with a trocar, had been introduced through the original puncture, that 
any considerable amount of pus escaped. Upon this occasion, about one 
quart of thick and exceedingly oflensive pus, occasionally mixed with air- 
bubbles, flowed through the canula; the orifice was now closed by a com- 
press of lint secured by adhesive straps. The following day the patient ap- 
peared somewhat less oppressed, but there was no very material improvement 
in his condition; on removing the compress there was a gush of oifensive 
pus, and it continued to flow until about the same amount had escaped as on 
the previous day; it was now observed that the percussion was tympanitic 
over a much larger extent than previous to the operation, but still the 
heart and liver had not regained their natural position ; the purulent expecto- 
ration had, however, decidedly diminished during the last twenty-four hours. 
Wine, bark, beef-essence, and other supporting measures were pursued, but 
his strength gradually failed and he expired just one week after puncturing 
the chest ; for several days preceding dissolution, not more than four or five 
ounces of pus escaped during the twenty-four hours. 

The body was examined thirty-six hours after death. The right pleura was 
coated throughout by a thick layer of semi-organized lymph, and contained a 
large amount of fetid gas and pus, of the latter not less than two or even 
three quarts still remained; several of the ribs, including the sixth, seventh, 
and eighth, were denuded and in a state of necrosis. The lung was com- 
pressed against the spine and firmly bound down by old adhesions ; in the 
upper lobe there was a large vomica lined by a cartilaginous membrane, and 
communicating with the cavity of the pleura by two fistulous openings; a few 
tubercles were scattered throughout the rest of the lung; the left lung also 
contained some disseminated tubercles; pericardium slightly inflamed; liver 
engorged ; other organs healthy. 

In this instance, the physical signs clearly revealed the existence of pneumo- 
thorax in connection with empyema, but it was quite impossible to determine 
whether the fistulous opening was the result of softened tubercles, or owing 
to ulceration of the pleura caused by the purulent collection. The previous 
history clearly showed that the disease commenced as an ordinary case of 
pleurisy, occurring in an individual of previous good health and without any 
hereditary tendency to consumption, and from these facts it appeared not im- 
probable that the ulceration of the lung was consequent upon the neglected 
pleurisy; and so in regard to the scattered tubercles detected after death, they 



42 



Pepper, Cases of Empyema, 



[Jan. 



too may have been the result of purulent absorption or vitiation of the system 
from chronic disease. At the same time, it should be remembered that stone- 
cutters are particularly liable to bronchial inflammation, sometimes even end- 
ing in pulmonary induration and ulceration ; the patient, however, persisted 
in stating that up to the time of his pleuritic attack he had not suffered from 
cough, or other symptom of diseased lung. 

For the above reasons, I am disposed to believe that if paracentesis had 
been performed at an early period of his disease, in all probability the lung 
would have escaped any serious organic disease ; but even when this mischief 
was done, there was still reason to believe that the life of the patient might 
be prolonged, and further disease prevented by aiding nature in her efforts to 
get rid of the pus through an external opening, and it was with this view 
alone that the chest was punctured under so many unfavourable circum- 
stances. 

Case TV. — During the summer of 1849, I was requested to visit a man, 
aged thirty-five years, said to be suffering with consumption. Upon inquiry, 
I found that he had been ill for about three months, and that his attack had 
commenced with the usual symptoms of acute pleurisy. His previous health 
had been uniformly good, nor was there any hereditary predisposition to pul- 
monary disease. At the time of my visit, he presented the following symp- 
toms : hectic fever, dyspncea, cough, purulent expectoration — equalling about 
six ounces per day — and considerable emaciation. The left lung appeared 
perfectly healthy, but the right side was distended; and, excepting at the 
summit, no vesicular murmur could be detected. In front and behind, how- 
ever, the respiration was amphoric, and frequently associated with metallic 
tinkling and gurgling, particularly when he coughed or suddenly moved from 
side to side. 

Up to the expiration of one month from the time I first saw him, there 
was no notable change in the symptoms, but it was then observed that the 
intercostal space between the sixth and seventh ribs was red and swollen, 
and also attended with indistinct fluctuation. The patient's strength had 
been sustained throughout by bark, wine, and beef-essence ; and a flaxseed 
poultice was applied over the inflamed part. On the following day, the most 
prominent part of the swelling was punctured with a lancet, which was im- 
mediately followed by six or eight ounces of thick pus, very similar to that 
which he had been expectorating for the last month; and throughout the 
further progress of the case it was observed that, when the external orifice 
was obstructed, the expectoration increased. Upon several occasions when 
the patient coughed, the pus commingled with air was driven through the 
opening with explosive force. From day to day the expectoration and dis- 
charge from the side became less and less, whilst at the same time his strength 
gradually improved under the use of tonics and a nutritious diet; and, in one 
month from the time of puncturing the chest, he left for the country in a 
greatly improved state of health. 

Three months after this he visited me at my oflice, and then presented the 
following condition : But little cough or expectoration, and, for the last two 
weeks, the opening in the side had entirely healed ; he had also gained flesh ; 
and, in fact, his whole condition had so far improved that it was with difficulty 
I recognized him as my former patient. The right thorax was much con- 



1852.] 



Pepper, Cases of Empyema. 



43 



tracted, and the shoulder of the same side greatly depressed; the respiration 
throughout this side was still very feeble, and in a measure masked by 
sonorous rales ; on the left, however, it was perfectly natural, or, perhaps, a 
little louder than usual. The patient was now about to resume his business, 
and from that time to the present I have not heard from him. 

Here, then, was a case of empyema associated with pneumothorax and 
great derangement of the constitution, and yet the patient in a great measure 
recovered from these serious lesions, and was once more enabled to enter upon 
the duties of life; nor can I divest myself of the idea that his restoration was, 
in a great measure, owing to the external opening. The fistula of the lung, 
in the present instance, was, most probably, the result of the pus ulcerating 
its way through into the bronchial tubes; but the escape of pus through this 
channel was so slow that irreparable injury to the lung, and, probably, even 
death itself, must have been the result without the counter opening in the 
side. 

During the summer of 1846, several cases somewhat similar to the above 
were admitted into the Pennsylvania Hospital; two of which presented a 
marked improvement in the symptoms upon the escape of pus from an opening 
in the side, and they both ultimately left the institution in a greatly improved 
state of health. An abstract of these cases, as reported by Dr. H. Harts- 
horne, formerly one of the resident physicians, may be found in the American 
Journal of Medical Sciences for October, 1848, p. 349. 

Case Y. — In the spring of 1850, I was requested by a medical friend to 
visit a lady, aged about thirty, suffering with an acute attack of pleuro-pneu- 
monia of the left side. From this she recovered but imperfectly, and, in the 
month of June, was sent into the country in the hope of restoring her feeble 
health. On the 5th of August, I was again requested to visit the patient, 
whom I then found suffering with all the symptoms of a local empyema, con- 
fined to the lower half of the left thorax. To the left of the cardiac region 
there was a pulsating tumour about the size of half a hen's egg. The swell- 
ing was painful to the touch and indistinctly fluctuating, and, by gentle pres- 
sure with the palm of the hand, it could be reduced in size — thus clearly 
showing that it communicated with the cavity of the pleura. Under these 
circumstances, it was deemed expedient to puncture it, and this trifling opera- 
tion was followed by a large discharge of healthy pus, to the great relief of 
the suffering patient. From time to time, I have visited this lady, and made 
the following note of her case in the latter part of September, 1851, or about 
eighteen months after the operation : Left side contracted and shoulder some- 
what depressed. Discharge of about two ounces of healthy pus from the 
side per day, but the quantity is variable, and alternates with the expectora- 
tion of the same kind of matter. At times, when she coughs, air and pus 
are forcibly expelled from the external orifice. She is now able to attend to 
her usual occupations, and can walk a mile or more without fatigue. The 
appetite is good, nor is there any hectic fever; but she still remains thin, and 
is occasionally somewhat oppressed, particularly when the external orifice is 
temporarily closed. The respiration and percussion are natural on the left 
side, excepting over a space of about four inches square near the root of the 



44 



Pepper, Cases of Empyema. 



[Jan. 



lung, wliere the percussion is flat and the respiration loudly bronchial. Over 
this part, also, there is great vocal resonance. 

From the above symptoms, it vras inferred that there still existed a circum- 
scribed abscess of the left pleura, communicating with the large bronchial 
tubes by a small fistulous opening — the surrounding pulmonary tissue being 
in an indurated condition. For the last year she has, with temporary omis- 
sions, persevered in the use of cod-liver oil, iron, and quinia ; and, judging 
from her present improved condition, it is by no means improbable that she 
may be ultimately restored to perfect health. 

In this, as well as in most of the above cases, I feel fully persuaded that, 
without the external opening, the chances of recovery would have been greatly 
diminished; and, indeed, in several instances, speedy dissolution must have 
been the inevitable result save for this cause. In every case, prompt relief 
followed the external discharge, and, whenever this was even temporarily 
arrested, the patient's distress was greatly increased. 

The operation of paracentesis thoracis has at all times been viewed with 
more or less distrust by many distinguished members of our profession; and 
although this prejudice is now rapidly disappearing, owing to the numerous 
instances in which the most beneficial results have followed the operation, 
there still remains much discrepancy of opinion as to the particular circum- 
stances under which this procedure is justifiable. And, indeed, it will be 
•found upon impartial investigation, that most of the disastrous results conse- 
quent upon it are fairly attributable to a want of proper discrimination in 
the selection of cases. Formerly, when the profession was in a great mea- 
sure ignorant of the physical signs indicative of effusions into the pleural 
cavities, it is not surprising that numerous instances of erroneous diagnosis 
and consequent faulty practice should have occurred ; such as puncturing an 
enlarged liver or spleen, or medullary tumour, under the impression that fluid 
existed in the thoracic cavity; or even opening the sound, instead of the dis- 
eased side, when such effusion absolutely existed, and thus giving rise to 
collapse of the healthy lung, and consequently to speedy dissolution. But 
now that the physical signs are known to afford great certainty in determin- 
ing the extent and character of thoracic disease, such errors cannot occur, 
except as the result of culpable ignorance or carelessness ; and it is owing to 
the great improvement in this department of our science that the operation 
of paracentesis is beginning to be viewed with more favour by the profession. 

It would be a work of supererogation, at the present time, to enter fully 
into details in regard to the physical signs indicative of intra-thoracic effu- 
sions, and my remarks under this head shall, therefore, be as brief as possible, 
Dulness on percussion is one of the most important indications of such a 
condition, and it exists to even a greater degree than in pneumonia, whilst at 
the same time the elasticity of the chest is entirely destroyed; in those cases 
where the pleural sac is not filled with fluid, the line of dulness can generally 
be varied by changing the position of the patient; occasionally, however, the 
fluid is limited by adhesions, and therefore, uninfluenced by position. The 



1852.] 



Pepper, Cases of Empyema. 



45 



distension of the chest should next claim our attention : in some instances, 
the circumference of the diseased side will exceed the healthy by one or two 
inches; whilst at the same time the intercostal spaces may be distended or 
bulging. In extreme cases, the heart will be displaced to the right or left, 
and the liver depressed by the superincumbent fluid. The absence of all 
vocal vibration also, constitutes an important indication. In like manner, 
auscultation is all important in forming our diagnosis ; thus, when the fluid 
is not considerable, a distinct agophonic resonance of the voice, and a pecu- 
liar modified bronchial respiration can generally be heard over the back and 
even in the axillary region; whereas, when the accumulation is very great 
these phenomena entirely disappear, or, at most, can only be heard over the 
root of the lung ; where most of the above signs co-exist, as is generally the 
case when there is an extensive eff"usion, it would be quite impossible to fall 
into any serious error as to the true nature of the disease. At the same time, 
however, it is important to attend to the previous history and accompanying 
functional disorders ; such as dyspnoea and inability to lie on the sound side, 
paucity of cough and expectoration. 

That there are cases of efi"asion, puriform or otherwise, which are not mani- 
fested by the above symptoms must be conceded ; as, for instance, when the 
fluid is confined between the lobes of the lung, or between the latter and the 
diaphragm ; and it is also well known, that when the efl"usion is but moderate 
and of gradual formation, no marked dyspnoea is induced, nor are the viscera 
displaced, or the side distended. It may happen in cases of local effusion, 
and where partial absorption has taken place, that the chest may even be con- 
tracted ; but under the above circumstances paracentesis is not called for, 
and no objection can, therefore, be urged against this operation from these 
occasional difficulties in diagnosis. Encephaloid degeneration of the lung 
has, in several instances, been mistaken for empyema; and when we bear in 
mind, that in this latter afi'ection the percussion may be perfectly flat, the 
side distended and elastic, the viscera dislocated and all respiratory sounds 
and rales entirely absent, it must be confessed, that ihuch discrimination is 
necessary in forming our opinion as to the true nature of the case. In one 
instance, where the question had been agitated as to whether paracentesis 
of the chest might be advisable," Dr. Stokes was enabled to pronounce upon 
the cancerous character of the affection mainly by the varicose condition of 
the veins of the diseased side, and the currant jelly-like sputa, in connection 
with the previous history of the case. These peculiarities do not always 
attend cancerous degeneration of the lung; and, moreover, it should be 
remembered that this disease is frequently complicated with empyema, 
rendering the diagnosis more and more obscure. The fact, that encepha- 
loid degeneration of the lung is generally associated with tumours of a simi- 
lar character occupying the mediastinum, and pressing upon the important 
organs contained in this region, will of itself frequently enable us to form 
a correct diagnosis; since, under these circumstances, we have violent pain 
No. XLY.— Jan., 1852. 4 



46 



Pepper, Cases of Empyema. 



[Jan. 



in the neck or shoulder, with oedema of the face, chest and arm, in connec- 
tion with dysphagia, hoarseness, and other symptoms caused by the pres- 
' sure of the tumour. Moreover, cancer of the lung is commonly attended with 
that peculiar condition of the system denominated cancerous cachexia ; and 
not unfrequently, we at the same time find malignant tumours occupying 
some of the external parts, as the glands of the neck or sides of the chest ; 
the previous history of the case will also greatly aid us in forming a correct 
opinion as to the true nature of the disease. The only other affection of the 
lung likely to be confounded with empyema is chronic pneumonia ; but in 
this disease the pulmonary induration is clearly indicated by the increased 
vocal resonance and vibration, want of distension of the side, viscid sputa, 
and mucous rales. 

Enlargement of the liver has occasionally been mistaken for empyema ; 
but such an error could always be avoided by strict attention to the physical 
signs already enumerated, such as dislocation of the heart, prominence of the 
intercostal spaces, and bronchial respiration at the root of the lung; besides 
which, the previous history and accompanying symptoms could not fail to 
remove any remaining doubt. These two affections are, however, very fre- 
quently associated ; for not only is the liver depressed in empyema by the 
superincumbent fluid, but, owing to the pressure of the collapsed lung and 
fluid upon the ascending cava preventing a free return of venous blood to the 
right auricle, it is also frequently much engorged. This condition, according 
to Dr. M'Donnell [Duhlin Journal of Med. Sci., 1844), occurs as well in 
empyema of the left as of the right side, and is owing to the supplementary 
action imposed upon the liver by the imperfect decarbonization of the blood 
in the lungs. Whatever may be the true explanation of this congestion, its 
existence certainly forms an important feature in the history of empyema, 
particularly in reference to the operation of paracentesis. The above author, 
also, reports several cases of "pulsating empyema" of the left side, where 
the puriform matter in the external cellular tissue communicated with the 
intra-thoracic abscess, ^nd thus received the indirect impulse of the heart. 
Under such circumstances, it is conceivable that these pulsating swellings 
might by the careless observer be mistaken for an aneurism, or a cancerous 
tumour ; but the locality of the swelling, its fluctuation, the absence of thrill 
and rasping sound, in connection with the extensive dulness of percussion 
and other physical signs of empyema, would at once distinguish it from an 
aneurism ; whilst the absence of the cancerous cachexia, and of the peculiar 
elasticity so characteristic of medullary tumours, would clearly show its non- 
malignant character. A mere abscess of the cellular tissue not communicat- 
ing with the cavity of the thorax could hardly be mistaken for empyema, since 
it would neither be increased by cough or diminished by pressure, as is gene- 
rally the case when the external swelling forms but a part of the intra-thoracic 
effusion. In like manner, by attending to the physical signs, functional dis- 



1852.] 



Pepper, Cases of Empijema. 



47 



orders, and previous history, an hepatic abscess can readily be distinguished 
from empyema. 

Pulmonary tubercles are so frequently associated with empyema, that it 
becomes exceedingly important to direct our attention to this complication, 
particularly when paracentesis is proposed, since the ultimate success of the 
operation must, in a great measure, depend upon the perfect integrity of the 
lungs. When the tubercles are numerous or softened, giving rise to solidifi- 
cation or vomica, the true state of the case is at once revealed by auscultation 
and percussion ; but on the other hand, when they are small and dissemi- 
nated, their presence is not indicated by any marked physical signs, and we 
are then obliged to rely more upon the previous history and general symp- 
toms. It is worthy of observation, however, that in uncomplicated empyema, 
the lung of the sound side, owing to its supplementary action and increased 
determination of blood, is generally more or less congested ; and it is, hence, 
no uncommon occurrence to find the respiratory murmur, in a measure, ob- 
scured by various rales, which might readily induce the belief that the dis- 
ease was complicated with bronchitis or tubercles ; under these circumstances, 
the expectoration occasionally becomes puriform (owing, as it has been sup- 
posed, to a species of vicarious action), and thus tends to confirm the erro- 
neous impression. At other times, the puriform sputa may proceed from a 
fistulous opening between the pleural cavity and the bronchial tubes of the 
compressed lung ; in such cases, however, the pleural sac generally contains 
more or less air, as evinced by the tympanitic percussion, and the peculiar 
gurgling induced by succussion. Under these circumstances, it becomes im- 
portant to ascertain whether the fistula has been caused by tubercular perfora- 
tion, or by the corrosive action of the pus in the pleura. When it can 
be ascertained that the patient, after suffering for some time with cough, or 
other symptom of pulmonary irritation, has been suddenly seized with acute 
pain in the axillary region, followed by extreme dyspnoea, we may reasonably 
conclude that any pleuritic effusion consequent upon such a seizure has been 
the result of tubercular perforation ; whereas, when the symptoms of pleurisy 
have occurred in the midst of perfect health, followed by a gradually increas- 
ing difficulty of breathing, and, at a still more remote period, by a sudden 
and very copious discharge of pus from the lungs, there can be but little 
doubt that the fistulous opening has been caused by the empyema bursting 
into the bronchial tubes. In those cases where the disease had been observed 
throughout, the physical signs would prevent all error upon this point. In 
connection with the diagnosis of empyema, it is important to observe, that, 
when this disease is complicated with pneumothorax and purulent expectora- 
tion, it by no means follows that a fistula of the lung necessarily exists ; the 
air in the pleural sac may be evolved by the unhealthy pus, and this is parti- 
cularly the case where there is necrosis of the ribs. In several instances of 
this kind, no opening into the lung could be found, notwithstanding the most 
minute examination; after filling the cavity of the pleura with water, the col- 



48 



Pepper, Coses of Empyema. 



[Jan. 



lapsed lung was forcibly inflated, but no air could be seen to bubble up from 
its surface ; in like manner, a most careful dissection of the false membranes 
failed to detect any fistulous opening. I may also mention, that in two of 
the cases, the gas contained in the pleura was tested with lime-water, with- 
out affording any milky precipitate, as unquestionably would have been the 
case had it contained any carbonic acid from the lungs; when treated, how- 
ever, with a solution of corrosive sublimate, it gave a black precipitate, clearly 
indicative of sulphuretted hydrogen. In regard to the purulent expectoration, 
under these circumstances it has been supposed to be a species of vicarious 
discharge from the mucous membrane of the bronchial tubes both of the dis- 
eased and healthy side; Drs. Stokes, Green, and M'Donnell, entertain this 
opinion, and allude to cases of recovery by purulent expectoration quite inde- 
pendent of any fistulous communication between the cavity of the pleura and 
lung; the last named author states that he has occasionally known empyema 
to be removed by a spontaneous diarrhoea. — {BuWm Journal of Medical Sci- 
ence for March 1844.) 

It still remains to be considered whether there are any means by which the 
character of the pleuritic effusion can be positively ascertained. The mere 
intensity of the symptoms is no evidence of puriform effusion, since this may 
result from a low grade of inflammation, whilst, on the other hand, the most 
severe forms of pleuritis frequently end in effusion of serum and lymph ; nor 
is the long duration of the effusion any proof of its puriform character, inas- 
much as it is well known that serum may remain in the pleural sac for many 
months without undergoing any important change. Hectic fever has always 
been considered as more or less characteristic of empyema, but occasionally 
this disease exists without any considerable constitutional irritation; so that, 
from the previous history and general symptoms alone, we could but arrive at 
a probable opinion ; more positive indications, however, may be derived from 
simple inspection of the chest. In cases of empyema, the lower intercostal 
spaces are frequently bulging to a much greater extent than ever occurs in 
hydrothorax, whether mechanical or inflammatory; whilst, at the same time, 
the superficial veins are oftentimes distended and tortuous. These pecu- 
liarities are probably owing to the high specific gravity of the fluid distending 
the intercostal spaces, and at the same time pressing upon the deep-seated 
veins, thus obliging the venous blood to return to the heart by a circuitous 
route. Dr. Stokes believes that the intercostal bulging depends more upon 
imperfect innervation or paralysis of the muscles than , upon the mere pres- 
sure of the pus; Dr. Roe is also of the opinion that a moderate amount 
of pus may by its irritating properties cause a relaxation or paralysis of the 
intercostal muscles, so as to give rise to a greater degree of distension than 
could be produced by the pressure of a much larger quantity of serum. 

After this brief view of some of the most prominent symptoms of empyema, 
particularly in reference to its diagnosis, it may not prove uninteresting to 
inquire under what particular circumstances the operation of paracentesis may 



1852.] 



Pepper, Cases of Empyema. 



49 



be indicated. In uncomplicated cases, and wbere the amount of pus is so con- 
siderable as to cause much distress, we see no good reason why the operation 
should be delayed. In opposition to this view, however, it may be urged, 
that by further procrastination the pus might ultimately find vent through 
the lung or intercostal spaces, or by both these routes, and be followed by 
the restoration of the patient, as has repeatedly happened under similar cir- 
cumstances; and, moreover, even without such openings, it is alleged that 
recoveries have taken place by a vicarious discharge from the bronchia or ali- 
mentary canal. But when it is remembered, that our therapeutic agents have 
but little influence in promoting the absorption of pus, that these agents, such 
as mercury, purgatives, &c., are contra-indicated in the impoverished state of 
the system which generally attends empyema, and that even supposing the 
pus might be absorbed, nothing but the most disastrous effects could result, 
such as metastatic abscess and other consequences of purulent infection ; it 
certainly does not appear reasonable to procrastinate in the forlorn hope that 
the unaided efforts of nature may open some safe channel for its escape. 
In the consideration of this question, it should also be recollected that the 
longer the pus is allowed to remain in the pleura the greater is the risk of 
carnification of the lung, necrosis of the ribs, and other serious complica- 
tions. The chief objection, however, urged against paracentesis, is the alleged 
injurious effects resulting from the admission of air into the pleural sac; but 
it is now generally conceded that all apprehensions on this point have been, 
in a great measure, unfounded. In twenty-four cases reported by Dr. Roe, 
the admission of air produced no detriment either by its pressure or decom- 
posing influence, and numerous cases of a similar character might be collected 
from the different periodicals ; this view is also in a measure confirmed by 
the well known fact that in traumatic pneumothorax, from fractured rib, or 
clavicle, the air produces no injurious effect, but is gradually absorbed as the 
cicatrized lung becomes inflated and restored to its natural position. But 
even supposing that the objection thus urged was valid, it certainly could be 
applied with equal force to the fistulous openings resulting from the corrosive 
action of the pus when abandoned to itself; when the lung has thus been 
perforated, it is no longer susceptible of expansion, but must remain collapsed 
until the fluid contents of the pleura are discharged, and the fistulous opening 
healed ; on the other hand, when the pus has worked its way externally through 
the intercostal spaces, the openings are often tortuous or ragged, easily ob- 
structed, and frequently associated with necrosis of the ribs. An appeal to 
facts also shows that the operation is fully sustained by experience : of sixteen 
cases of empyema, reported by Dr. T. Davis, in which paracentesis had been 
performed, twelve recovered ; and of forty-four cases collected and reported 
by Dr. H. Boe, in the Medico- Chirurgical Transactions, vol. xxvii., the ope- 
ration proved successful in thirty-two instances, showing that more than two- 
thirds, or nearly three-fourths of the whole number recovered. Besides those 
just alluded to, numerous other successful cases have recently been reported 



50 



Pepper^ Cases of Empyema. 



[Jan. 



in the various journals both of Europe and this country; and amongst the 
advocates for the operation may be enumerated many of those best qualified 
to form a correct opinion in thoracic diseases, such as Forbes, Stokes, Wil- 
liams, Watson, and numerous others equally entitled to respect upon this sub- 
ject. 

When, however, the empyema is attended with a fistulous opening of the 
lung, sufficient to allow the pus to escape freely by expectoration, paracentesis 
is certainly not called for ; but when the opening is small, or so obstructed as 
to prevent the free passage of the fluid and thus give rise to increased oppres- 
sion, a counter-opening in the side is clearly indicated ; by this procedure not 
only will the pus be more rapidly and safely evacuated, but the perforation of 
the lung may heal, and thus allow the collapsed organ to regain its natural 
dimensions. When tubercles exist, with or without perforation of the lung, 
the expediency of the operation is, to say the least, extremely doubtful ) and 
the most that can be hoped for from it, under these circumstances, is a tem- 
porary prolongation of life. Much of the disrepute, which is by some attached 
to paracentesis-thoracis can, in a great measure, be traced to the fact that 
cases similar to those just referred to, have but too often been subjected to 
this operation. 

Thus far allusion has chiefly been made to paracentesis as applicable to 
empyema or purulent collections in the cavity of the pleura, and it now remains 
to add a few words in regard to its expediency in hydrothorax, whether acute 
or chronic, mechanical or inflammatory. Rapid and very copious efi"usion as 
the result of acute pleurisy occasionally gives rise to the most distressing 
orthopnoea, or even speedy dissolution; under such circumstances, the action 
of medicines may prove too tardy for the relief of the patient, and as asphyxia 
is imminent, puncturing the chest is not only admissible, but absolutely de- 
manded by the urgency of the case. It is well known that, as a general rule, 
pleuritic efi'usions can be removed by appropriate treatment, such as bleeding, 
calomel, squill and digitalis, the various hydragogue cathartics, diuretics, dia- 
phoretics, and blisters; but, occasionally, all these means fail to promote absorp- 
tion, whilst at the same time the eff'usion is gradually increasing and threaten- 
ing a protracted and agonizing death ; in such instances nothing but a resort 
to paracentesis can save the life of the patient, and it is incumbent upon the 
physician to recommend its performance before the powers of life have so far 
failed as to prevent the system from rallying after the removal of the fluid. 
In Europe, and particularly in France, this operation is frequently adopted in 
cases of extensive and recent pleuritic efi'usion, and it must not be concealed 
that, in some instances at least, there is reason to believe it has been resorted 
to prematurely ; but, whilst in this disease as in croup, the operation should 
only be viewed as a dernier resort, it is still important that it should not be 
delayed until asphyxia has so far progressed as to materially interfere with its 
ultimate success. In many cases of inflammatory hydrothorax, the pleura is 
completely invested by a thick layer of lymph ; and, under these circum- 



1852.] 



Pepper, Cases of Empyema. 



51 



stances, it is apparent tliat the fluid contents can be but slowly absorbed, or 
may even become as it were encysted, and there remain for many months or 
years without undergoing any important change j "in such cases, though delay 
may not lead to ulceration of the lung or necrosis, as in case of empyema, 
it is evident that but little is to be hoped for from our therapeutic agents or 
the expectant plan of treatment ', and that, therefore, paracentesis should be 
resorted to whenever the oppression is very considerable, more especially so, 
since the longer this operation is deferred the greater will be the difficulty in 
the lung regaining its natural position. 

Dr. Roe reports in all some twenty-six cases of inflammatory hydrothorax, 
in which paracentesis had been performed, and of these, seventeen recovered; 
showing, at least, that this procedure is not as hazardous as has been by some 
supposed. Other instances might be adduced to show that a timely resort to 
the operation might, in most instances, save the life of the patient. 

In mechanical hydrothorax, where the eflfusion depends upon disease of the 
heart, or forms but a part of general dropsy, as in the advanced stage of granular 
degeneration of the kidneys, nothing but temporary relief could be expected 
from tapping the chest ; the effusion here forms but an accidental complication 
to a more serious disease which has already impaired the powers of life ] and 
hence it is, that paracentesis is attended with much danger under these circum- 
stances. Dr. Davis reports three cases of this character, in all of which the 
operation proved fatal; other fatal cases have also been recorded; and hence 
this practice has been in a great measure abandoned in this form of hydro- 
thorax. 

In regard to the operation itself, there are some points upon which a few 
remarks may not be inappropriate at the present time. Some discrepancy of 
opinion still exists as to the exact locality where the puncture should be made ; 
but, it is now generally conceded, that the most eligible position is in the fifth 
intercostal space, about midway between the sternum and spine, or just poste- 
rior to the digitations of the serratus major; this part of the chest being gene- 
rally most free from adhesions, and at the same time sufficiently remote from 
the other important organs. When the fluid points externally, constituting 
^' empyema by necessity,'' the puncture may be made with a lancet in the 
most prominent and yielding part of the swelling ; but, in all other instances, 
a small sized trocar, such as is used for tapping in hydrocephalus or hydrocele, 
should be preferred, the point of the instrument being exceedingly sharp so 
that the false membranes which occasionally line the costal pleura, may not 
be carried before it, and thus frustrate the operation. By some, it is recom- 
mended that the fluid should be removed as far as practicable at the time of 
the operation ; and with this view, it is urged, that pressure should be made 
over the epigastrium and side of the chest ; but, in regard to this question, 
much must depend upon the condition of the patient, the character of the 
fluid, and duration of the disease. When the lung is much compressed and 
bound down by false membranes, it would not be desirable, even were it prac- 



52 



Pepper, Cases of Empyema. 



[Jan. 



ticable, to draw off all the fluid at once, nor would it be prudent to pursue this 
course in feeble and exhausted subjects; the most that should be done under 
these circumstances, would ' be to allow an escape of fluid sufficient to remove 
the tension and oppression caused by the displacement of the mediastinum 
and diaphragm, the rest being allowed to flow off from day to day in accord- 
ance with the contraction of the chest, the expansion of the lung, and the 
rallying strength of the patient. Much the same plan is recommended by 
Dr. R. Townsend, in his elaborate article on empyema, in the Cyclopsedia of 
Practical Medicine, where he states that the fluid should be allowed to escape 
only so long as the stream continues full and uninterrupted, and till tension 
is removed : a similar opinion is also entertained by Dr. Stokes, and other 
writers of note. In recent cases of empyema or serous effusion, and where 
there is good reason to believe that the lung is neither carnified or bound down 
by lymph or false membrane, the fluid may be evacuated at once, since the 
lung will gradually rise as the superincumbent pus or serum is removed. 
So long as any pus remains in the cavity of the pleura, the puncture will 
generally remain open; and it will also be found, that as the tension is re- 
moved, the external orifice will no longer correspond with the opening through 
the intercostal space, so that it is not necessary to render the integuments tense 
before making the puncture, as has been recommended with the view of form- 
ing a valvular opening, and thus preventing the entrance of air. Occasion- 
lly, however, the opening is disposed to close, and under these circumstances 
it is expedient that the orifice should be dilated by a small piece of waxed 
sponge or lint secured by an adhesive strap : some, on the other hand, have 
preferred that it should heal, and the operation be repeated from time to time 
according to the necessity of the case. A remarkable instance of this kind 
may be found in the London and Edinhurgh Monthly Journal, for 1850, re- 
ported by Dr. Peddie, in which twelve distinct operations were performed in 
the course of three years, at the end of which time the patient's health was 
entirely restored; the whole amount of pus removed being about four gallons. 
In case of more serous effusion, there can be no doubt as to the propriety of 
allowing the puncture to close; for, under these circumstances, the fluid that 
may remain will frequently be absorbed, or, at least, it can have no injurious 
effect upon the lung or ribs as in the case of puriform matter ; nature also 
appears to point out this course, since in most instances where the chest has 
been punctured for serous effusion the wound has promptly healed ; whereas 
in cases of empyema, it has been known to remain open for many years 
without very materially interfering with the general health. With the view 
of effecting a radical cure in case of chronic empyema, it has been recom- 
mended to inject the pleural sac with various astringent or stimulating fluids, 
such as decoctions of white oak bark, or solutions of iodine ; in several 
instances the fluids thus injected have appeared in the expectoration, owing 
to the existence of a fistulous communication between the bronchia and 
pleura, and yet the patients have ultimately recovered. In the Western Jour- 



1852.] 



Pepper; Cases of Empi/ema. 



53 



nal of Medicine and Surgery (May, 1845), a case of successful treatment by 
injection of white oak bark is reported by Dr. Sneed, and others of a similar 
character have been recorded, but the propriety of such a procedure requires 
confirmation by more extended observation. 

When the lung has been long compressed and is, at the same time, firmly 
bound down by old adhesions, it can never regain its natural position by the 
mere removal of the superincumbent fluid ; and hence it is that the side must 
remain permanently contracted ; in many instances, however, of this kind the 
side does not become so far sunken as to reach the collapsed lung, so that a 
small space occupied by pus or serum still remains between it and the ribs, 
and under these circumstances, fistulous openings have been known to remain 
for the remainder of life. At other times, the lung of the sound side, 
owing to its increased function, becomes hypertrophied, and by displacing 
the mediastinum finally obliterates the sac remaining on the diseased side : 
within a few months I examined the body of a man, who, for two years pre- 
vious to his last illness, had suffered with chronic pleurisy of the left side; the 
lung of this side did not exceed the size of his fist, and yet the sac of the left 
pleura was completely obliterated by the contraction of the chest and the dis- 
placement of the mediastinum from the pressure of the right lung, which had 
attained an unusual development; the heart, of course, was also forced to the 
left side. Dr. Stokes, however, attributes the dislocation of the heart in such 
cases, rather to the contraction of the mediastinum than to its displacement by 
the hypertrophied lung ; and in those cases where the absorption has been ex- 
ceedingly rapid, this most probably is the true explanation. 

The peculiar deformity resulting from the absorption or removal by para- 
centesis of extensive pleuritic effusion, is greatly modified by the age of the 
patient and the duration of the disease. When recent, the contraction of the 
chest and consequent depression of the shoulder rapidly disappear as the lung 
regains its natural dimensions; but the reverse of this is true when the disease 
has been of long standing, and the lung long compressed and invested by false 
membranes. In adults, or at a more advanced age, owing to the firmness of the 
osseous structure, the deformity is generally much less than in early life ; and 
for the same reason the displaced parts are much slower in regaining their 
natural positions, requiring sometimes a period of several years ; whereas, in 
childhood, the parts being more yielding, the displacements are more exten- 
sive and rapidly formed, and at the same time much sooner restored to their 
normal condition. Quite recently, I had under my care a little girl aged 
about three years, suffering with acute pleurisy and extensive effusion ; ab- 
sorption progressed rapidly, and at the end of two months the chest was greatly 
contracted, the shoulder depressed, and the spine curved to such an extent 
that the little patient completely lost her balance, and in attempting to walk 
would fall towards the deformed side; and yet, notwithstanding the great dis- 
placement of parts, she had entirely regained her usual figure at the expira- 
tion of about four months from the commencement of her disease. In the 



54 



Squibb, Report of Cruise in Frigate Cumberland. [Jan. 



fall of 1849 J I saw, in consultation with Drs. Fox and Morris, a little child, 
aged eighteen months, suflfering with acute empyema of the left side; in this 
instance, paracentesis was performed by the first named gentleman, and al- 
though the chest became excessively contracted, the deformity had nearly 
disappeared by the end of eighteen months, at which time the general health 
was also entirely restored. I forbear, however, entering into further details of 
this very interesting case, since it will be reported in full at some future period 
by Dr. Fox. 



Art. III. — Summary Report of the Hospital Department of the U. S. 
Frigate Cumberland, during a cruise to the Mediterranean, from July 
Idth, 1849, to July 9th, 1851. By Edward R. Squibb, M. D., Assistant 
Surgeon U. S. N. 



The ship was in commission during . . . 719 days. 

At anchor in the various ports, . . . 541 " 

At sea, ....... 178 " 

Entire distance sailed, by log, .... 18,266 miles. 

Original number of officers and men on board, . . 493 

Received during the icruise, to supply deficiencies, . . 109 

Total number making any portion of the cruise, . . 602 

From these were transferred sick, .... 52 

" " transferred to other ships, ... 70 

" discharged, ..... 32 

" deserted, ..... 17 

died, 13 



Of the total number 351 made the entire cruise on board. 
" " " 251 made a part of the cruise only. 
" " " only 92 escaped the register of sick, and of these 9 had 
been on board less than three months. 

The extreme ages on board were 15, and 64 years ; 56 persons below the age 
of 21, and 15 above 49. 

The average age in 472 individuals, from whom it could be obtained with 
tolerable accuracy, was 28 years nearly. 

Of the total number, the places of birth ascertained with the greatest care and 
pains, are as follows : — 



Born in the United States, including 43 officers, . . 238 

" Ireland, 107 

" " England, Wales, and Nova Scotia, ... 60 

" " Germany and Holland, 4 in Prussia, . . 42 

" " Italy, Sicily, and 2 in Malta, ... 28 

" " Sweden, Denmark, Hanover, Norway, and Finland, 25 

" " Scotland, ...... 21 

" *' France, and French Canada, ... 16 

" " Spain, and West Indies, .... 7 

" " Austria, ...... 5 



1852.] Squibb, Report of Cruise in Frujate Camherland. 55 



Born in Russia 4, and Hungary 3, . . . . 7 

" " Sardinia 3, and Portugal 1, . . . . 4 

" Switzerland 1, Isle of France 1, . . . 2 

Uncertain, 33 claiming to be of the U. S., . . . 40 

Dividing the sum of the days of each man's service on board, by the number 
of days of the cruise, the average number of the ship's company for the entire 
cruise is obtained ; say, 453 souls. 

Of the total number on board during the cruise, 510 were registered and 
treated for injuries and diseases, by average 3'6 times. 
118 were sick once, and 81 twice. 

7 were sick ten times; 4 eleven times ; 2 twelve times ; and 1 fourteen times. 
10 were sick for one day only ; 14 for two days ; and 11 for three days only. 
55 were sick over one hundred days ; and 5 over two hundred days. 



Quarters of 


From 




"Were 


Of an 


Average 




Sick 


a year. 






admitted 


average 


daily sick 


Deaths. 


transfers. 








sick. 


dutation of 


list. 






First quarter July 20 to Oct. 19, 


1849 


341 cases 


8.55 days 


32.21 


2 


IS 


Second " 


Oct. 19 to Jan. 18, 


1850 


287 


11.6 " 


36.12 


2 


17 


Third « 


Jan. 18 to April 19, 


1850 


308 " 


16.1 


(( 


54.89 


5 


11 


Fourth " 


April 19 to July 20, 


1850 


232 « 


13.7 


(C 


35.09 


1 




Fifth '« 


July 20 to Oct. 19, 


1850 


191 " 


12.2 


(( 


26.09 


1 


5 


Sixth « 


Oct. 19 to Jan. 18, 


1851 


141 « 


12.3 


(( 


19.9 


1 




Seventh " 


Jan. 18 to April 19, 


1851 


229 « 


12.5 


cc 


33.05 


1 




Eighth " 


April 19 to July 9, 


1851 


114 - 


15.6 


it 


24.95 








Total 


1843 cases 


12.82 days 


32.8 


13 


52 



The first quarter comprises an epidemic of cholera and diarrhoea, 
third " " " varioloid. 

" seventh " " catarrh. 

" eighth " is imperfect in time, in consequence of some 35 cases 
having been sent to the hospital at Chelsea, near the end of the cruise. 

During 102 days the daily sick list was over 44 
88 " " " below 21 

Maximum of the daily sick list, 79 
Mean " " 32-8 

Minimum " " 7 

Maximum average for any single month; say Feb., 1850, 64-46 daily. 
Minimum " " " Nov., " 14-8 " 

Maximum length of complete cases, 144 days. 
Mean " " " 12-82 " 

Minimum " " " 1 " 

25 cases occurred, of a duration of more than 60 days. 

7 " " " 90 " 

93 " " one day only. 

Maximum average duration of cases for any single month, 19-6 days. 
Minimum " " " " 5-5 " 

Total number of days' labour paid for by the Government during the 

cruise, ........ 325,507 

Number of days' labour lost by sickness, .... 23,626 

or more than 7 per cent. 



56 



Squibb, Report of Cruhe in Frigate Cumberland. [Jan. 



Total expenditures in the hospital department, exclusive of the pay 

of officers and hospital steward, .... $1,505 75^ 

Bill for the hire of a vessel used as a varioloid hospital in the har- 
bour of Messina, ...... 161 00 

10 per cent, for usage and loss on articles of furniture, and stores 

returned in good order, . . . . . 87 15 



Total cost of the cruise, . ^ $1,753 90^ 

or nearly $2 44 per diem. 

An average list of 32"8 men daily, at a whole cost of |2 44, is 7*439 cents 
daily cost to government for each case treated. 

The whole cost, including officers and steward's pay and rations, is about 44 
cents per diem for each sick man treated. 

Total amount of rations stopped, in lieu of which a diet was supplied by the 
hospital department, ...... $1,288 00 

The register exhibits 1,843 cases of injuries and diseases; separable into 205 
cases of injury, and 1,638 cases of disease. 

Summary of Injuries. 

Burns and scalds, . . 5 cases. 

Contusions, . . . 74 " 

Fractures, . . . 6 " 

Luxations, . . . 3 " 

Concussion of the brain, . 1 " 

Hernia, . . . . 8 " 

Sprain, . . . . 27 " 

Wounds, . . . . 81 " 

Of the first head, 2 were burns and 3 scalds. 

Of the fractures, 2 were metacarpal, 1 ulnar (right), 1 forearm (left), 1 nasal, 
and 1 clavicle (left). 

Of the luxations, 1 was metacarpocarpal, 1 sub-luxation of the 2d joint of the 
left thumb, and 1 not noted. 

Of the hernias, all inguinal, 2 were of the left, 4 of the right side, and 2 re- 
admissions of the same case from neuralgic pain in the part. There was one 
case of umbilical, co-existing with one of the inguinal hernias, but it remained 
habitually prolapsed and demanded no attention. The subject was an Italian 
trombone player. 

Of the sprains, 11 were of the back or loins; 1 of the side; 7 of the inferior 
extremities ; 2 of the superior extremities ; and 4 not noted. The remaining 2 
were re-admissions of the same case. 

Of the wounds, 29 were contused-; 26 punctured ; 14 incised; and 12 lacerated. 
None were of grave character or followed by serious results. One, an oblique 
stab in the right side of the back, was dangerous and tedious in consequence 
of constitutional depravity. This, with the sub-luxation of the thumb, were the 
only cases that did not terminate on board, and with ordinary celerity. 

A majority of all these cases of injury were treated with simple water dress- 
ings ; a few with medicated water dressings, and the remainder with the ordinary 
poultices, plasters, and ointments in common use ; and with varying methods. 

Some two years ago the writer took occasion to extol the advantages of simple 
dressings in surgery, in a paper subsequently published from the bureau, in the 
American Journal of the Medical Sciences. Without any loss of confidence in 
the methods there so strongly recommended, farther experience indicates that 
there are conditions of irritability in some simple sores where the mucilaginous 
sheathing obtained through light thin elm or linseed poultices, carefully ma- 
naged, is valuable beyond any other dressing. If this is true in some simple 
sores, the fact acquires additional importance where constitutional or mechanical 
causes exist as complications. To say that the object of treatment in injuries 
is to prevent or remedy complications, is but another expression of the fact that 
nature repairs her own injuries herself. That no aid to natural action can be 



1852.] 



Squibb; Report of Cruise in Frigate Cumhcrland. 



57 



» cases. 
2 

1 case. 



given, or should be attemptccl. All available treatment may be protection and 
support to healthful activit}'', and proportional opposition to all departures from 
it. And the aim of treatment is best, when most simply attained. 

Summary of Diseases. 

Of the Nervous System. 
Dementia, ... 1 case. Sea Sickness, 
Epilepsy, ... 6 cases. Paralysis, 
Delirium Tremens, . 8 " Periodical Headache, 

Neuralgia, . . . 10 " 

Of the organs of Special Sense, and Superficial Structures 
Ophthalmia, . 
Conjunctivitis, 
Hordeolum, . 
Otitis, . 
Epistaxis, 
Odontalgia, 
Cutaneous Eruptions, 
Variola and Varioloid, 
Vaccinia, 
Erysipelas, 



7 


cases. 


Excoriations 


13 




Ulcers, . 


6 




Chilblain, 


11 


(( 


Phlegmon, 


1 


case. 


AVhitlow, 


3 


cases. 


Paronychia, 


23 


(< 


Abscess, 
Bunion, 


61 


<( 


2 


ii 


GEdema, 


1 


case. 





11 

23 
2 
108 

13 
7 

15 
2 
1 



cases. 



Rheumatism, 



Catarrh, 

Bronchitis, 

Hcemoptysis, . 

Pneumonia, . 

Pleuropneum_ony, 

Phthisis, 

Asthma, 



Of the Muscles and Joints. 
. 134 cases. Arthritis, 

Of the Chest and Respiratory Organs. 
. 277 cases. Pleuritis, 



40 - 
2 - 
7 " 

1 case. 

2 cases. 
4 " 



Pleurodynia, . 
Valv. dis. of heart, 
Hypert. of heart. 
Aneurism of aorta, 
Angina pectoris. 



Of the Alimentary Canal and its Appendages. 



Stomatitis, . . .14 cases. 
Gas. derang't & dyspepsia, 138 



Gastritis, 
Cholera morbus, 
Colic, 
Enteritis, 
Diarrhoea, 
Dysentery, 



Tonsillitis, 

Parotitis, 

Hepatitis, 



1 case. 
7 cases. 
13 

1 case. 
143 cases. 
7 " 



Colitis, . 
Constipation, 
AYorms, 
Hgemorrhoids, 
Anal fistula. 
Anal fissure, 
Ascites, . 



Of the Glandular Structures. 
. 61 cases. Hepatic derangement, 
8 " Splenitis, 
3 " Adenitis, 



Of the Urinary Organs and their Appendages. 

Vesical irritation, . . 2 cases. Phymosis 
62 " ' - ' 

5 " 

9 << 



Gonorrhoea, 
Gleet, . 

Stricture of urethra. 
Balanitis, 



Aflection of sperm, cord, 
Orchitis, 
Hydrocele, 
Syphilis, 



2 cases. 



14 cases. 
9 " 
1 case. 

1 " 
1 

2 cases. 



cases. 
37 " 
5 " 
6 

1 case. 
1 " 
1 " 



6 cases. 
1 case. 

22 cases. 



6 cases. 
1 case. 
18 cases. 
1 case. 
106 cases. 



Of the Genei^al System. 
Marasmus, ... 1 case. 
Fevers, . . . .91 cases. 
Asiatic cholera, . . 14 " 



58 Squibb; Report of Cruise in Frigate Cumberland. [Jan. 

Remarks — First, upon the Diseases of the Nervous System. — The case of 
dementia was incomplete, having been sent on board for passage home from 
another ship, and was transferred to the hospital at Chelsea, without having 
exhibited any evidences of dementia. 

Six admissions from epilepsy. Three of these occurred in the progress of 
one case which commenced and terminated on board. That the causes in 
this case were sedentary confinement, uncongenial associations, and mastur- 
bation, is probable from the good results of exercise, new occupations, and 
moral influences attempted in conjunction with the use of tonics and regimen. 
A second case also recurred once, and had its commencement, and probably 
its favourable termination on board. It seemed to have been caused by the 
intestinal irritation of tape-worm in a plethoric individual of 22 years old, 
but recurred after the worm had been for some time expelled and the symp- 
toms gone. Counter-irritation to the neck, and purgatives, were followed by 
a successful termination of the case. The third case neither commenced nor 
terminated on board; and the attacks were at such long intervals, and 
seemed to be of so slight an inconvenience to the subject of them, that he 
never applied for treatment, except by an occasional purgative to discharge 
the quantities of indigestible " duff," by which they were often produced and 
foreseen. 

The 8 cases of delirium tremens were all promptly accessible, light, and 
favorable in termination. 

Of the neuralgia, 2 cases, at least, were probably feigned. 

The absence of sensible evidences of some of these neuroses renders them 
the least manageable of feigned diseases. 

Second. Organs of Special Sense and Superficial Structures. — 7 admis- 
sions from ophthalmia, of which 4 were recurrent attacks. The 3 cases were 
as general in the tissues attacked as the name implies, and at least 2 were of 
scrofulous or scorbutic complication. Iodine, internally and externally, seemed 
to be the effective agent in treatment. 

Four of the 11 cases of otitis were probably scrofulous, developed by the 
diet and air of ship-board. 

The cutaneous diseases were commonly long, tedious, and intractable, 
increasing in proportion as the cruise advanced, showing at least that the 
condition of life was favourable to their continuance, and thus that a per- 
sisting cause was opposing treatment. Two-thirds of the cases were pustular, 
a few vesicular or bullar, and others papular. The prevalence of phlegmon, 
paronychia, and whitlow, increasing with the length of time on board, is 
another expression of the existence of conditions favourable to diseases of the 
superficial structures. Diet, personal habits, moisture, and crowded sleeping 
places, are the most prominent among these conspiring conditions, and should 
claim proportional attention. It is worth the consideration of all who are 
interested in the efficiency of our only national representatives to the congress 



1852.] Squibb, Report of Cruise in Frigate Cumberland. 59 

of the nations of the world, how far these conditions may be necessary evils 
in supporting the discipline of men-of-war. That men should be crowded into 
18 inch spaces to sleep, on a berth-deck, in order that the beams of a well 
ventilated gun-deck may not be defaced by hammock hooks, is senseless. But 
when it is remembered that the fundamental element of efficiency is health ; 
and that health should be robust in order to insure the necessary amount of 
resistance to the hardships of an unnatural life, the climax must have sur- 
prised all who saw and thought upon the hygienic condition of a ship wherein 
the customs of past ages had degenerated into laws jealous of innovation, and 
therefore resisting improvement. Scanty ventilation, damp decks, and a 
diet that never varies, in climates and seasons always varying, and all these 
administered with a judgment that will not be enlightened by the means 
placed at hand, are not conditions under which a healthy, energetic, progres- 
sive race of men are properly represented to the world. There is probably 
no community of 453 individuals in any other condition of life that will 
exhibit 1600 cases of disease within two years; and yet nothing is spared in 
legislation or expense, whereby it is supposed that such a community may be 
well maintained, except that an imperfect executive judgment is sanctioned 
in its imperfections, and relieved of all responsibility for errors. Errors of 
judgment are criminal when they come to affect life, in defiance or disregard 
of the means of correction. 

Of variolous disease there were 61* cases, occurring within 78 days from 
the first of January, 1850. All on board who did not exhibit satisfactory 
evidences of vaccination or small-pox, had been vaccinated some months 
before, but it was from a virus that may have lost its efficacy, as only one 
or two equivocal pustules could be obtained. It has been remarked, by sur- 
geons of experience and observation, that vaccination does not succeed as 
certainly, or progress as regularly on board of ships as under the ordinary 
circumstances; and the history of this attempt strengthens the opinion, for 
the virus was carefully obtained, and well kept. 

Of the 61 cases, 10 from their violence, the size and progress of the pus- 
tules, and the deep pitting of the skin, may be considered as true variola. 
Four of these were fatal. One of the fatal cases had a tolerable vaccine 
mark, and died on the fourth day of the eruption without the ordinary pro- 
gress toward maturation. Another died on the fifth day of the eruption, a 
third on the seventh day, and the last after maturation. The six remaining 
cases were tedious in convalescence, all suffering much from successive large 
boils in various parts of the body, for some 18 days during and after the 
falling of the crusts. The average duration of fatal cases was 12 days, with 
6 and 25 for the extremes; whilst the average for the 6 remaining cases was 
64.7 days, with 36 and 88 for the extremes. ' 

Fifty-one cases of varioloid of an average duration of 20.2 days, with 3 and 
52 for the extremes. The longer cases include consequent attacks of phleg- 
mon, rheumatism, debility, &c. The single case of 3 days' duration occurred 



60 



Squibb, Report of Cruise in Frigate Cumherland. 



[Jan. 



in a man of about 40, distinctly marked on the face by a small-pox that he 
remembered well. The fever of this case was well marked, and subsided on 
the appearance of the eruption. Twenty-four hours after the appearance of 
the eruption it had begun to decline, and the man was fit for duty. 

A great majority of the eruptions of this epidemic made their appearance 
on the back first, then on the arms, and then on the face, there being very 
few notable exceptions to this succession. In many cases it was confined to 
the back, and in others to the back and arms. 

No case was registered as varioloid in which there was no eruption, 
although there were many cases, say 17 in which the fever, headache, pains 
in the back and limbs, &c., went through so regular a course of 48 hours as 
to warrant the belief that it was variolous. These cases are included in the 
ephemeral fevers of this report. 

Third. Of the Muscles and Joints. — Rheumatisms were commonly the 
most intractable of the diseases that occurred during the cruise ; whilst in 
number they hold the fourth rank. Among feigned diseases they hold the 
first rank, and are not unfrequently resorted to as substitutes for complaints 
that are better founded. These circumstances make it quite useless to make 
up their averages from the data of our register. It is impossible to say that 
a man has no rheumatism when he says he has, whilst it is subversive of 
good military discipline to expose sick men, or men who cannot be shown 
to be well, in the line of their duty. 

Fourth. Of the Chest and Respiratory Organs. — 277 cases of catarrh 
occurred in 196 individuals; 135 men had a single attack only; 47 had 2 
attacks; 9 had 3 attacks; 4 had 4 attacks; and 1 had 5 attacks. 

The maximum duration of catarrhs was 24 days. 
" mean " " 5.63 days. 

minimum " ^' 1 day. 

" average duration of all the first attacks was 5.38 days. 

" " second 8.127 days. 

" third " 9.33 days. 

Over 43 per cent, of the average number on board suifered from catarrh; 
and nearly 14 per cent, suffered twice or more. 

By grouping together these affections that occur chiefly from similar 
causes, such as catarrh, bronchitis, pneumonia, pleuritis, pleurodynia, tonsil- 
litis, and say half the rheumatisms, a sum of 475 cases is obtained, occurring 
in 196 individuals. Thus more than 42 per cent, of the average number on 
board suffered twice or oftener from diseases whose common causes are simi- 
lar. No person is registered as a patient unless he is too sick to do duty, 
and thus a great many cases of catarrh, and other light affections, escape 
these tables, although they are frequently treated during one, two, or even 



1852.] 



Squibb, Report of Cruise in Frvjafe Cumberland. 



51 



three or more days. Therefore the actual number of cases that occur is one- 
fifth greater than the register exhibits, of catarrhs, and perhaps one-seventh 
greater of all light affections. 

Catarrhs occurred among officers and among men in the proportion of 
about 10 to 43 per cent. ) thus increasing the per centage among the latter 
by diminishing the aggregate number. 

These catarrhs were almost exclusively pectoral, for it was rare to see a 
common coryza, or " cold in the head/' during the cruise. 

Three times during the cruise, catarrhs became epidemic, when numbers 
would be upon the list at the same time. These epidemics were in Septem- 
ber and in November 1849, and in March and April 1851. 

Forty cases of bronchitis occurred in 33 individuals; 8 of these cases are 
imperfect, the patients having been sent home for better treatment. These, 
and similar imperfect cases in other diseases, are excluded from the tables in 
making up the averages. 

Maximum duration of complete cases 62 and 109 days. 
Mean " 22.375 days. 

Minimum " 2 and 5 days. 

Of these cases one proved ftital in a second attack, having occurred from 
the extreme exposure incident to the duties of ship's cook's assistant. It is 
necessary, in order to clean the large boilers, that the cooks should get into 
them, and as they are never cool during the day, the cooks are subjected 
often to sudden and extreme temperatures. 

Another of the patients had phthisis subsequently, and died in 49 days. 

Seven cases of pneumonia occurred in 7 individuals. 

One of these became typhoid, and terminated fatally in 26 days. 

Another severe case had a long convalescence, complicated by catarrhs and 
rheumatisms. Its duration was 144 days. Not being altogether pneumonia, 
or easily separable, this case is omitted in the averages. 

Maximum duration of cases 78 days. 
Mean " " 38.2 days. 

Minimum " 11 days. 

Altogether the longest cases of the report. 
Fourteen cases of pleuritis in 13 individuals. 

One was sent home after 50 days' illness, recovered from the pleuritis, 
but suffering from a chronic cough that did not improve on ship-board. This 
case is admitted in the average tables, the duration of the primary disease 
being set down at 27 days. 

Maximum duration of cases 29 days. 
Mean " " 9.57 days. 

Minimum " " 4 days. 

No. XLY.— Jan , 1852. 5 



52 Squibb^ Report of Cruise in Frigate Cumberland. [Jan. 

Nine cases of pleurodynia in 8 individuals. 

Maximum duration of cases 12 days. 
Mean " 5.33 days. 

Minimum " ^' 2 days. 

From these, all rheumatisms, sprains, and muscular affections have been 
excluded, so that they are properly grouped with pleuritis, of which they 
may be considered as the commencing stage, arrested in development. 

Of these 80 last-mentioned cases, two only, and these of pneumonia, were 
bled from the arm. Both these cases terminated favourably beyond the 
average time. In the whole register, no more than five individuals were 
bled, and none copiously. Although the common indications to venesection 
were not infrequent, the obvious local tendency to typhoid depression in all 
long-continued cases was opposed to such treatment. Moderate local deple- 
tion seemed commonly to produce here the full impression of venesection on 
shore, and patients would rarely bear a repetition of this with advantage. 

Of the diseases of the heart and great vessels of the chest, one case of 
ossifio degeneration about the jnouth of the aorta was fatal in an officer of 
about 59 years old. 

The case of aortic aneurism was sent home early in the cruise. 

Fiftli. Of the Alimentary Canal and its Appendages. — The 14 cases of 
stomatitis occurred in 6 individuals, in four of whom recurrences took place 
from time to time as an expression of scrofulous or scorbutic influences. 

The terms gastric derangement," and dyspepsia,'^ used here, are any- 
thing else than definite; and the 138 cases collected under this head include 
all those where gastric symptoms were primary, and no speciality developed. 
Hence tables of these cases would be without value. They were generally of 
short duration, much below the total average, and present no prominence for 
study or interest of more importance than their causes. Among these causes 
the debauchery among men on liberty stands foremost. 

Men would return, or be brought on board after twenty-four or forty-eight 
hours' liberty on shore, in a condition to develop or favour the progress of 
almost any disease. The time allowed them is not long enough to produce 
delirium tremens in men accustomed to the daily use of small quantities of 
spirits, and hence most of these gastric irritations bear the same relation to 
delirium tremens that the limited time does to the time necessary for the 
production of full delirium from the same causes. Other cases again approxi- 
mate gastritis in the same way; while still another group presents degrees of 
persisting irritation, that, without being serious in themselves, affect very 
unfavourably the gonorrhoea and syphilis commonly commencing at such 
times. 

Next in the rank of causes come improprieties and irregularities of diet. 
These cases are commonly of shorter duration, yielding at once to the effect 
of the habitual emetic and prescribed diet. 



1852.] 



Squibb, Report of Crui&e in Frvjate Cumberland. 



53 



There is one compound, made from the ship's ration, that is chargeable 
with many of these cases, through the gluttony induced by the natural appe- 
tite for this variety in food. Every Thursday the week's rations of flour and 
dried fruit are issued and made into a batter, with grease from salted meats, 
technically ^' slush." This batter, when boiled in a bag, with an iron spoon 
in the centre of it, is called " duff." By the common appetite for this article 
of diet, it appears that the materials of which it is composed are highly 
important to the economy; but that, coming in this indigestible form, and 
once a week only, and forming then, with molasses, almost the entire dinner 
of the day, it excites gluttony and gastric disorder. 

The indiscriminate buying and eating of fruit, ripe and unripe together, 
and at irregular and often long intervals, is another cause of these cases. 

Whether the customary issue of the spirit ration before, rather than after 
meals, is more conducive to health, admits of some doubt, and is worthy of 
consideration in this connection. 

There were no cases of confirmed, prolonged dyspepsia on board, whilst 
flatulence, from which colics rarely arose, was very common, giving rise to 
the bad habit to which sailors, more than any other class, seem addicted. 

143 cases of diarrhoea occurred in 119 individuals. 

97 men had a single attack; 20 had two attacks; and 2 had three attacks. 
5 cases were chronic, of an average duration of 30.2 days. 
Of the remaining 138 cases — 

The average duration of all the first attacks was 4.017 days. 

" second " " 3.857 " 

Over 26 per cent, of the average ship's company suffered from diarrhoea, 
and 5 per cent, suffered twice or more. 

Maximum duration of cases of diarrhoea 19 days. 
Mean " " 4.03 days. 

Minimum " " " 1 day. 

Seven cases of cholera morbus occurred in 7 individuals of an average 
duration of 3.14 days. 

These cases, without exception, occurred within the first six months of the 
cruise. 

Seven cases of dysentery occurred in 7 individuals, of an average duration 
of 7 days each. 

This group of diseases is important, from occupying the second place in 
number of cases. 

Twice in the cruise these diseases were epidemic. Once at New York, in 
July and August, 1849, and again at Alexandria, in Egypt, in August, 1850. 
Epidemic cholera was prevailing at both places at the time, and cases occurred 
on board ship in conjunction with diarrhoeas. The origin of that at Alex- 
andria, if not due to the epidemic influences of cholera, was probably due to 
the drinking of Nile water. 



54 Squibb, Report of Cruise in Frigate Cumherland. [Jan. 

The cases occurring at these times were best treated by the combination of 
opium, camphor, and capsicum, used in the earlier stages of cholera; whilst 
those occurring at other times were easily controlled in the usual manner. 

There occurred on board 4 cases of tape- worm, all of which were successfully 
treated by oil of turpentine. One of these resisted a thorough treatment 
with pomegranate root bark, and another resisted repeated active purgation. 
The ''kousso'^ (flowers of the briaria anthelmintica?) was to have been tried, 
had any case resisted the turpentine. But the cost of this new remedy was 
so extravagant as not to warrant the trial without necessity. The oil of tur- 
pentine was given in a single dose of one fluidounce, with two fluidrachms of 
castor oil to insure purgation ; and this, in no case, had to be repeated, al- 
though three months were passed on board after the last case. The strangury 
anticipated from the remedy did not occur. 

This disease seems to have been favoured by the condition of life, inde- 
pendently of diet, as one of the cases occurred in an officer. 

Sixth. Of Glandular Structures. — 61 cases of tonsillitis occurred in 54 
individuals. 

49 men had a single attack only; 4 had two attacks; and 1 four attacks. 
33 of these patients are also registered with catarrhs, and 6 of them more 
than once, whilst in 28 the tonsillitis was the sole effect of the similar causes. 

Maximum duration of cases, 14 and 18 days. 
Mean " 5.115 days. 

Minimum " 2 and 1 days. 

A large majority of them terminated in resolution, under the influence of 
purgation, and stimulant and astringent gargles. 
22 cases of adenitis in 20 individuals. 

18 men were affected once only, whilst in 2 the tumour recurred and sup- 
purated after having once subsided. 

Maximum duration of cases, 41 and 44 days. 
Mean " 18 days. 

Minimum " " 4: " 

Of these cases the tumours all occurred in the groin except one. They 
were all probably quite independent of syphilis, and were tedious and intract- 
able. A great majority of them suppurated, forming indolent, painless, 
troublesome abscesses of difficult treatment. Only two of these patients ex- 
hibited any syphilitic disease during the cruise, and this in both was subse- 
quent to the adenitis. 

Seventh. Of the Urinary Organs and Apj^tendages. — 62 cases of gonor- 
rhoea in 56 individuals. 

50 men had the disease once, and 6 had it twice. 

32 cases occurred in the first half of the cruise, and 30 in the second half. 



1852.] Squibb; Report of Cruise in Frigate Cumberland. 



55 



Maximum duration in the first half of cruise, 49. Second half, 35 days. 
Mean " " 18.69. " 16.6 

Minimum " "3 "3 

Eight cases of gonorrhoea occurring in combination with syphilis are not 
included in the enumeration. 

Two cases were complicated by orchitis, and two by obstinate rheumatism. 
These complications are subtracted in making the tables. 

There occurred 5 cases of gleet ensuing upon gonorrhoea, of an average 
duration of 19.2 days. 

These gonorrhoeas were variously treated. 

By comparing results, the most successful method seems to have been that 
by injection of sulphate of zinc and sulphate of morphia, one grain each to 
the fluidounce of water, with copious drinking of water or mucilaginous in- 
fusions : and in chordee cases, a plaster of thinned extract of belladonna to 
the course of the urethra, or penis generally. 

Rest in the horizontal position in all acute stages, with cold water dressings 
and mucilaginous iDjections before and after urination where the inflammation 
ran high. 

Where such injections were ordinarily, that is, carelessly used, they seemed 
to do harm. The immediate effect of active purgation seemed to be detri- 
mental. 

Both the cases of stricture of the urethra were reproduced from old ones, 
by gonorrhoea. Both were dilated. 

One hundred and six cases of syphilis occurred in 86 individuals. 

Sixty-nine men had one attack only; 15 two attacks; 1 three attacks, and 
1 four attacks. 

Of these, 7 cases were secondary; 1 tertiary, and 8 complicated with go- 
norrhoea. 

Forty-four cases had swellings in the groin. 26 in the left groin, 17 in the 
right, and one not noted. 31 of the 44 suppurated, 15 in each groin and 1 not 
noted. 40 cases consisted in irritable, superficial, spreading ulcers, chiefly of 
the corona and prepuce ; whilst only three cases of the old Hunterian chancre 
are noted, one of which was followed by swelling in the groin without suppu- 
ration. 

In 12 instances, swellings existed in the groin when the cases first came 
under notice, and in four instances, at least, the sores on the penis and tumour 
in the groin were on opposite sides of the body. 

Maximum duration of cases, 93 days. 

Mean " 28.3 " 

Minimum " 5 

There is a great probability that the length^ of these cases does not belong 
to them as syphilis ; but that the causes of adenitis, operating upon or through 
syphilis, produced many of the swellings of lymphatic glands, and protracted 
them all. 



56 



Squibb, Report of Cruise in Frigate Cuniberland. [Jan. 



Hence tlie difBculties of treatment depend not so much upon the over- 
coming of diseased action, as upon causes, or combinations of causes persistent 
beyond easy control. Certain it is that these combinations must be recognized 
before they can be controlled, for adenitis would scarcely be well treated by 
the mercurials often resorted to in syphilis. 

The syphilis, both primary and secondary, of the older writers, seems to 
have materially degenerated as it occurs on board ship ; for, during two cruises, 
wherein about 20 per cent, of the whole number serving on board have con- 
tracted syphilitic disease once or oftener, the writer has seen no more than 7 
or 8 cases of chancre as it is described by old authors. 

Eightli. Of the General System. — 91 cases of fevers occurred in 71 in- 
dividuals. 

60 men each had a single attack only; 7 had two attacks; 4 three attacks, 
and 1 five attacks. 

42 cases were ephemeral fevers, occurring in 42 individuals. 

Maximum duration of cases, 12 and 16 days. 
Mean " 5.22 days. 

Minimum " 2 

25 cases were intermittent, occurring in 15 individuals. 
10 men had each a single attack only; 2 had two attacks; 2 three attacks, 
and 1 five attacks. 

Maximum duration of cases, 15 and 29 days. 
Mean " " 8.2 days. 

Minimum " 2 " 

15 cases of catarrhal fever, occurring in 15 individuals. 
Maximum duration of cases, 34 days. 
Mean 14 
Minimum ^^ 3 and 2 days. 

One of these cases proved fatal, on the 14th day, in a boy 17 years old. 
Seven cases of continued fever in 6 individuals. 

Maximum duration of cases, 29 and 41 days. 

Mean " " 25 days. 

Minimum " 10 

One case of remittent fever of 8 days' duration; and 1 case of typhoid 
fever, fatal in 4 days, in a boy of 15 years old. 

Not one of these fevers, intermittents excepted, occurred within the first 
five months of the cruise. 

The fevers called ephemeral were peculiar. 23 of the 42 cases occurred 
during the 78 days of epidemic varioloid, and 17 of these, at least, pursued 
a course so regular and limited, that they may be regarded as imperfect va- 
rioloid, or as the effect of varioloid contagion. 



1852.] Squibb, Report of Cruise in Frigate Cumberland. 



57 



The remaining 19 cases are scattered throughout the cruise, all subsequent 
to the first group except one case. 

They were fevers of irregular character, commonly commencing with de- 
bility, chilliness, headache, &c. They were often of a high grade, with som- 
nolency, delirium, and full high pulse for a day or more, then gradually 
declining, to terminate in perspiration. They were of speedy convalescence, 
and not liable to relapse or recurrence. No term seems to apply to them 
more definitely than that adopted. 

Those called catarrhal were also peculiar. All but two cases occurred 
during an epidemic of catarrh in March and April, 1851. Commencing with 
severe catarrhal symptoms, the patients became lethargic and finally somno- 
lent, with rapid full pulse, and hot, dry and flushed surface. When awakened, 
or the bed-clothing moved, they would complain of chilliness, take what was 
ofi'ered them, wrap themselves up closely, and go at once into the same sound 
sleep again. The most acute cases were those that slept soundest and longest, 
and these commonly terminated soonest, in more rapid convalescence. After 
24 or 36 hours of this fever and sleep, the skin would become first moist 
and then wet, without any apparent change in the pulse or heat of surface, 
and the paroxysm would terminate in a profuse and prolonged sweating, which 
would saturate the bedding and mattress to an unusual extent. The pulse 
and heat of surface would gradually subside with the progress of this stage. 
In the longer cases, the fever, without running so high, would remit and recur, 
with occasional delirium and restlessness, and with a disposition to typhoid 
depression in the later stages. Such cases had usually a long convalescence. 

The cases of continued fever difi'ered from simple remitting fever chiefly 
in that the remissions were very slight, and quite without regularity; and that 
the fever had a tendency to exhaust and depress the vital forces without any 
special complication. This and the ephemeral group will have more character 
and be better appreciated, probably, if viewed in connection with the com- 
mencing force of causes which in full activity and development produce typhus 
or ship fevers. 

The fatal case noted as typhoid fever was a very grave and interesting one. 
About 36 hours before death, a general livid eruption appeared upon the surface ; 
and the blood was so changed in character that it did not coagulate, but oozed 
from some leech bites at the epigastrium, even after the actual cautery had 
been resorted to. Death was preceded for several hours by passive hemor- 
rhages from the anus. 

This case terminated 4 days before the commencement of the first well- 
marked case of varioloid, and the second case of varioloid occurred after an 
interval of nearly two weeks after the first. 

The fatal case occurred in a midshipman; the first two cases of varioloid 
occurred in passed-midshipmen \ and the third case of varioloid in a drummer- 
boy, who slept near the midshipmen's quarters, and near the door of the 
boatswain's room, in which the fatal case was nursed. 



58 Squibb, Report of Cruise in Frigate Camberland. [Jan. 



When the midshipman died, there was no difference in the opinions of the 
three medical attendants as to the typhoid or typhous character of the disease. 
Some trifling circumstances of the case, however, when afterward considered 
in connection with the variolous epidemic in its commencement, led the junior 
of the three medical officers to suspect that the fatal case was variolous, with- 
out his knowing, up to the present time, whether any such suspicion existed in 
the minds of the older and more experienced officers. While the epidemic 
was in progress, it would have been unwise to call in the influence of a fatal 
case, and after it had passed the subject was not thought of until the going 
over of the records for this report. 

Fourteen cases of Asiatic cholera occurred, of which 3 died. 

Maximum duration of cases, 12 days. 
Mean " 4.909 days. 

Minimum " 1 day. 

Twice during the cruise cholera occurred on board. Once at New York, 
before sailing, where were 11 cases and 2 deaths; and again at Alexandria, 
in Egypt, 3 cases and 1 death. 

No case has been registered as cholera where collapse and rice-water dis- 
charges did not occur, yet there were a great many registered as diarrhoeas, in 
both epidemics, which were undoubtedly cholera arrested in its development, 
and which would have been called cholera in any general hospital report. 

When, upon entering the harbour of Alexandria, cholera was found to pre- 
vail there, the surgeon of the ship advised the captain to have no communi- 
cation with the shore. The captain's judgment, however, being opposed to 
the surgeon's advice, the ship rode out a quarantine of five days, during which 
she was " filled up" with Nile water from the cisterns under the town. After 
the quarantine, another day was passed at anchor, and by this time so many 
cases of diarrhoea and cholera had occurred as to render it expedient to go to 
sea. The ship was accordingly towed out the following morning, about the 
time at which the fatal case occurred and terminated in a few hours in per- 
fect collapse. 

The disease abated immediately upon going to sea, and upon desisting from 
the use of the Nile water. 

In closing a report, throughout which so much of the unusual amount of 
disease is attributed to dampness, debauchery, and the police economy of the 
ship, one suggestion for general improvement may not be out of place. 

It is supposed by the writer that the surface of the planking of a ship's 
berth-deck might be so saturated and glazed with common yellow wax that 
water would not be absorbed. And that, like the tile floors , of many French 
hospitals, they would be easily cleaned and easily kept clean. The facility 
with which such an experiment might be tried is additional reason for re- 
spectfully urging its consideration upon the Bureau. 

Phiiadelphia, August 22d, 1851. 



1852.] Sims, Treatment of Vesica- Vaginal Fistula. 59 



Art. ly. — On the Treatment of Vesica- Vaginal Fistula. By J. Marion 
Sims, M. D., of Montgomery, Ala. [With twenty-two wood-cuts.] 

Vesico-Vaginal Fistula — an abnormal communication between the blad- 
der and vagina, allowing an involuntary discharge of urine — is produced gene- 
rally by tedious labour. The impacted foetal head, jamming the anterior vaginal 
parietes against the symphysis pubis, obstructs the circulation of the parts, 
which results in a slough of greater or less extent, according to the degree and 
duration of the impaction. Almost the only hope of preventing so serious a 
disaster under such circumstances is the timely resort to instrumental delivery. 
By this means I have seen the slough confined to the vaginal mucous mem- 
brane, where, otherwise, it would unquestionably have extended entirely through 
the vagino-vesical septum. It occurs principally in first labours where the pelvis 
is small, the soft parts unyielding, and the foetal cranium large ; but I have 
seen it in those advanced in life, who had given birth previously to many 
children. Authors are disposed to attribute the accident, in many cases, to 
the awkward use of obstetrical instruments; but, from a careful analysis of 
these cases, and from my own experience, I am well satisfied that for one case 
thus produced, their judicious application has prevented it fifty times. 

Other causes produce it occasionally, such as a prolonged retention of a pes- 
sary in the vagina, a calculus or other foreign body in the bladder, abscesses, 
venereal ulcerations, &c. I have seen one case where the whole base of the 
bladder was destroyed by a corroding ulcer, which, originating in the cervix 
uteri, extended forward to the urethra. Whatever may be the cause of this 
distressing affection, it is a matter of serious importance to both surgeon and 
patient that it be rendered susceptible of cure. 

Its diagnosis is sufliciently easy. Incontinence of urine, following a tedious 
labour after a lapse of from one to fifteen days, will always prove its existence. 
But to determine the exact size, shape, and relative position of the artificial 
opening requires some nicety of examination. The consequences of the in- 
voluntary discharge of urine are indeed painful. The vagina may become in- 
flamed, ulcerated, encrusted with urinary calculi, and even contracted ; while 
the vulva, nates, and thighs are more or less excoriated, being often covered 
with pustules having a great resemblance to those produced by tartar emetic. 
These pustules sometimes degenerate into sloughs, causing loss of substance, 
and requiring a long time to heal. The clothes and bedding of the unfor- 
tunate patient are constantly saturated with the discharge, thus exhaling a 
disagreeable effluvium, alike disgusting to herself and repulsive to others. 

The accident, per se, is never fatal ; but it may well be imagined that a lady 
of keen sensibilities so afflicted, and excluded from all social enjoyment, would 
prefer death. A case of this kind came under my observation a few years 



60 



Sims, Treatment of Vesico- Vaginal Fistula. 



[Jan. 



since, wliere the lady absolutely pined away and died, in consequence of her 
extreme mortification on ascertaining that she was hopelessly incurable. 

The relative position of the fistula has served generally as the basis of a 
classification. Thus we have : — 

1st. The urethro-vaginalj where the fistula is confined to the urethra. 

2d. Those fistulee situated at the neck of the bladder, or root of the urethra, 
destroying the trigonus vesicalis. 

3d. Those of the body and bas-fond of the bladder, of which, Yelpeau says, 
" there is no fact, up to the present time, Which proves indisputably that they 
have ever been cured." 

4th. The utero-vesical, where the opening communicates with the body or 
cervix of the uterus. 

I have never met with one of the last-named class ; but of the others I have 
seen a great variety, embracing almost every possible shape and size. 

The position of the patient for the operation, the speculum, the means of 
vivifying the edges of the fistulous opening, the suture apparatus, and the 
catheter which I shall describe, are, I believe, original with myself, having 
been suggested by the peculiarities of individual cases. The final perfection 
of these mechanical contrivances has been the slow work of experiment. 

At the first, I had three cases, upon which T operated about forty times, but 
failed in every instance to eflfect a perfect cure, though succeeding so far as to 
encourage me to persevere. Now, I think I may say that almost every case of 
this hitherto intractable afiection is rendered perfectly curable. 

Before detailing my operation, it may be interesting historically to take a 
brief survey of the surgery of this disease up to the present time. 

For the last half century, though surgeons have laboured assiduously to 
cure it, they have almost always been unsuccessful. Cases have, now and 
then, been remedied, but they were so few that no general principles of treat- 
ment could be established, and, consequently, no certainty of success, in any 
single instance, could be predicated. 

The suture was, of course, the first surgical appliance that suggested itself to 
the mind of operators. It was used in all its various modifications without 
success. The great difficulty of applying the suture, and its signal failure, 
caused surgeons to invent a number of instrumental apparatuses, all of which 
are clumsy and complicated. 

As a curiosity, let me here introduce a description of the apparatus of Lal- 
lemand, the distinguished professor, of Montpellier : — 

*' It is composed — 1st, of a large canula about four inches long ; 2d, of a 
double hook, which is moved in the principal instrument by means of a stem, 
in such manner as to push it out, or to make it enter its sheath ; 3d, of a circular 
plate which terminates the other extremity of the canula, and which would 
hinder, if necessary, this latter from penetrating too deep into the urethra ; and, 
4th, of a cork-screw spring, intended to draw forward the small hooks as soon 
as they are inserted in the posterior lip of the fistula. The canula, being passed 
into the bladder, allows of our pushing the two small hooks into the vagina 
through the vesico-vaginal septum, Avhich latter is supported by the left fore- 



1852.] Sims, Treatment of Vesico-Vagmal Fistula. 61 

finger. By making a turn of the screw, tliey are kept in this position ; a pledget 
of lint, or fine linen, designed for protecting the tissues, is then placed between 
the front part of the urethra and the external plate of the canula ; finally, we 
relax the spring whicli acts then, at the same time, by making traction on the 
posterior lip with its hooks, and by pressing backwards the lower Avail of the 
urethra by means of the circular plate, or tlie^ lint, which serves as its point 
d'appui. By a mechanism which would be too long for description, we may 
regulate the stop of the spring in such manner that there will only result from 
it a moderate degree of pressure, though suf&cient for bringing the two borders 
of the fistula in contact." — {Velpeau, vol. iii. p. 852.) 

The apparatuses of Lewziski, of Dupuytren, of Laugier, of Fabbri,aiid others, 
are equally complicated, quite as unfit to fulfil the proper indications of treat- 
ment, and, by experience, have proved as v^holly worthless. 

Others have attempted to improve different stages of the operation. Thus 
Colombat praises his spiroidal needle for passing a whip suture in longitudinal 
fistulas, and M. Sanson has proposed to enlarge the urethra by a double litho- 
tome for the purpose of carrying the finger through the urethra into the blad- 
der, merely to depress the fistula toward the vulval opening ; while Wutzer 
proposes, and performs in a great number of cases, the high operation of para- 
centesis vesicae, confining his patient for several days on her abdomen, by 
means of cushions, straps, and buckles. 

These are referred to as historical facts, and not for any good that could 
possibly result from them. 

While all these formidable contrivances, and the suture, have failed so sig- 
nally, cauterization has but little more to boast of in the way of success. Very 
small fistulous openings have occasionally been reported as cured by the appli- 
cation of the nitrate of silver, a catheter being retained in the bladder ; but, 
in fistulas of any size, it has proved entirely abortive. 

To show how utterly hopeless have been all our efforts heretofore, we may 
allude to the suggestion of some of the French surgeons to apply the Taliaco- 
tian method of anaplasty to this operation, which has actually been repeatedly 
performed by Boux, Jobert, and others ; and, also, to the operation of M. 
Vidal, for an "obturation of the vulva," whereby the bladder and vagina be- 
come a grand compound receptacle of the urine and menstrual secretion. It 
is an idle waste of time to dwell longer on means so perfectly ineffectual, not 
to say mischievous. 

But have no useful, practical suggestions been made, as yet, by any one on 
the treatment of vesico-vaginal fistula ? Yes : two names stand out in bold 
relief amongst those who have devoted some time and attention to this sub- 
ject. I allude to our own countryman, Mettauer, who uses leaden sutures; 
and to the indefatigable Jobert, who is the author of the operation of auto- 
plastie par glissement. The first, by his plan, has cured several cases ; while 
the latter has achieved a greater degree of success than any other surgeon. 

Thus, all that we know on the subject worth knowing is due to America 
and France; while German and British surgery have done comparatively 
nothing for the amelioration of this loathsome and troublesome disease. ' 



62 



Sims^ Treatment of Vesica- Vaginal Fistula. 



[Jan. 



Many of our systematic works pass it over in silence, or dismiss it with a 
few remarks discouraging all attempts at treatment. Samuel Cooper, in his 
great Surgical Dictionary, ^oqb, not introduce the subject even by name; 
while Liston devotes less than a page to it. Alluding to the application of 
the heated wire, he says : " By this means a small opening may occasionally 
be made to heal up. But when the communication is to a large extent, but 
little hope remains to the patient." Fergusson, Gribson, and others say nothing 
about it ; while Millar dismisses it as summarily as did Liston. But how 
could it be otherwise, when its mechanical treatment is so imperfect that no 
general principles could be laid down ? 

It is not my intention to allude to all that has been attempted by different 
surgeons ; but it is equally a duty and a pleasure here to chronicle what has 
been done by our own countrymen who lay any claims to originality or credit. 

The first successful case in this country is, I believe, by Dr. Hayward, of 
Boston. The following is his description of the operation : — 

" The patient was placed on the edge of a table, in the same position as in 
the operation for lithotomy. The parts being well dilated, I introduced a large 
bougie into the urethra, and carried it back as far as the fistula. In this way 
I was able to bring the fistula downwards, so that the opening was brought 
fairly into view. The bougie being then taken by an assistant, I made a rapid 
incision with a scalpel around the fistula, about a line from its edges, and then 
removed the whole circumference of the orifice. As soon as the bleeding, 
which was slight, had ceased, I dissected up the membrane of the vagina from 
the bladder, all around the opening, to the extent of about three lines. This 
was done partly with the view of increasing the chance of union, by presenting 
a larger surface, and partly to prevent the necessity of carrying the needles 
through the bladder. I then introduced a needle, about the third of an inch 
from the edge of the wound, through the membrane of the vagina, and the 
cellular membrane beneath, and brought it out at the opposite side, at about an 
equal distance. Before the needle was drawn through, a second and a third 
were introduced in the same way ; and these being found sufiicient to close the 
orifice, they were carried through, and the threads tic^htl}'' tied. Each thread 
was left about three inches in length." — [Am. Journ. Med. Sciences, Aug. 1839.) 

Besides this case. Dr. Hayward has recently reported eight others, operated 
upon since August, 1840, two of which were entirely successful. He says : 

" The operation was done in every instance by ligature. The result has, on 
the whole, been satisfactory. Anything that is calculated to remove this 
infirmity, or to lessen in the slightest degree the sufi'erings of the individuals 
who are^afilicted with it, should be made known. 

" I had never seen the operation done until I did it myself, nor could I find any 
description of the mode which others had adopted, that was sufficiently clear 
and explicit to be of much service. I had, therefore, to take such a course as 
I thought safe, and at the same time likely to efi"ect the object, viz : the closure 
of the fissure. I do not know that others may not have operated precisely in 
the same way ; but if they have, I am not aware of it. 

"I performed the operation twenty times, but it was done on nine patients 
only, one being operated on six times, another five, two twice, and five once.'' — 
{Boston Med. and Surg. Journal, vol. xliv., No. 11. April 16, 1851.) 

Dr. Pancoast, of Philadelphia, has operated successfully in two cases, by 

the following method : — 

" The peculiarity of the operation consists, virtually, in attaching the two 
sides of the anormal opening firmly together, on the principle of the tongue and 



1852.] 



Sims, Treatment of Vesico- Vaginal Fistula. 



63 



groove, so as to get four raw surfaces in contact, and thus increase the proba- 
bilities of union by the first intention. For this purpose it is necessary that 
the margins of the fistula should have considerable thickness, and when not 
found in this state, they are to be thickened by repeated applications of lunar 
caustic ; or, better still, of the actual cautery. 

"Having exposed the fistulous orifice as thoroughly as possible with a Char- 
rifere's speculum, from which the sliding blade has been removed, an assistant 
at the same time drawing the vestibulum well up towards the front of the 
pubis, my first object in the operation is to split the most posterior margin of 
the fistula to the depth of half an inch. I next pare off the edges of the other 
lip of the fistula, so as to bring it into a wedge shape ; first reverting it as much 
as possible with a small blunt hook, and trimming off the mucous membrane 
on the side next the bladder with the curved scissors or scalpel, and then de- 
taching, in like manner, the vaginal mucous membrane, to the breadth of three- 
quarters of an inch, along the whole extent of the lip. This was a very difficult 
but most important part of the process. Having checked the bleeding by the 
use of astringent applications, my next object is to insert the raw wedge or 
tongue, into which one of the lips of the fistula has been converted, into the 
groove which has been cut in the other, and hold them in close connection. 
This I accomplish by the means of a peculiar suture that might be called the 
plastic, and in the same way that I have described its application in reference 
to some plastic operations in my Operative Surgery ; and in the American Jour- 
nal of the Medical Sciences for October, 1842. 

"When the sutures are knotted firmly, the tongue or wedge will be found im- 
movably imbedded in the groove. The sutures I leave for two weeks or more, 
or until they become loose. A gum catheter should be kept in the bladder to 
prevent the accumulation of urine. To keep the inflammation from running 
to a destructive height, a bladder of cold water should be applied for thirty-six 
hours to the vulva. 

*'0n the second or third day, I direct the frequent injection of a solution of 
zinci sulph. into the vagina, in order to increase the tone of the parts. On 
the fourth or fifth day, I apply to the line of union a solution of lunar caustic 
with a camel's hair pencil. This application should be made twice in the twenty- 
four hours, the solution being gradually increased in strength. Union by first 
intention may be expected to take place under this treatment to a considerable 
extent; at such points as it should fail to occur, union by second intention is 
to be promoted by the use of lunar caustic in substance, so as to raise a bed of 
granulations on the raw surfaces of the lips, while they are held in contact by 
the plastic suture. 

In one case, there was a complete destruction of a cross section of the whole 
urethral structure, near the neck of the bladder ; in the other, there was an 
elongated orifice in the has-fond of the bladder, which would more than admit 
the end of the finger." — [Med. Examiner, May, 1847.) 

Dr. Mettauer's operation, the peculiarity of which consists in the use of 
leaden sutures, is described in the Ar)i. Journ. Med. Sciences for July, 1847, 
to which I beg leave to refer the reader for particulars. 

Having thus briefly alluded to what has been done, up to the present time, 
for the treatment of this affection, I shall now proceed to detail my own ope- 
ration. 

I conceive that I may claim originality: 1st. For the discovery of a method 
by which the vagina can be thoroughly explored, and the operation easily per- 
formed. 

2d. For the introduction of a new suture apparatus, which lies imbedded 
in the tissues for an indefinite period without danger of cutting its way out, 
as do silk ligatures. 

And 3d. For the invention of a self-retaining catheter, which can be worn 



64 



Sims^ Treatment of Vesica- Vaginal Fistula. 



[Jan. 



with the greatest comfort by the patient during the whole process of treat- 
ment. 

Of the position of the patient for the operation. — With the exception of 
Yelpeau and Chelius, all other operators, even Johert, recommend that the 
patient be placed on the back as in the operation for stone. 

Yelpeau* sajvS, "A round-shaped mattress is placed under the helly, in such 
manner as to enable her to keep her thighs flexed, lohile lying upon her abdomen. 
An assistant keeps the vagina dilated by means of a large gutter of metal, horn, 
or thin wood." 

Cheliusf directs " the patient to be placed on her belly upon a table covered 
with a mattress, so that she may kneel near its edge, with her head and chest 
bent forwards, and supported with small bolsters. The operator sits between 
the patient's thighs, upon a seat of proper height, so that his arms should not 
soon tire.'^ 

In 1845, previously to the translation of either Yelpeau or Chelius, I hit 
upon the proper plan of exploring the vagina in these cases ; but to the latter 
is due the first published account of even a hint towards that method. 

In order to obtain a correct view of the vaginal canal, I place the patient upon 
a table about 2 J by 4 feet, on her knees, with the nates elevated, and the head 
and shoulders depressed. The knees must be separated some 6 or 8 inches, the 
thighs at about right angles with the table, and the clothing all thoroughly 
loosened, so that there shall be no compression of the abdominal parietes. An 
assistant on each side lays a hand in the fold between the glutei muscles and 
the thigh, the ends of the fingers extending quite to the labia majora; then, by 
simultaneously pulling the nates upwards and outwards, the os externum opens, 
the pelvic and abdominal viscera all gravitate towards the epigastric region, 
the atmosphere enters the vagina, and there, pressing with a weight of 14 lbs. 
upon the square inch, soon stretches this canal out to its utmost limits, afi"ording' 
an easy view of the os tincse, fistula, &c. To facilitate the exhibition of the 
parts, the assistant on the. right side of the patient introduces into the vagina 
the lever speculum represented in Fig. 1, and then, by lifting the perineum, 
stretching the sphincter, and raising up the recto-vaginal septum, it is as easy 
to view the whole vaginal canal as it is to examine the fauces by turning a 
mouth widely open, up to a strong light. (See Fig. 4.) This method of exhibit- 
ing the parts is not only useful in these cases, but in all afi"ections of the os and 
cervix utl3ri requiring ocular inspection. The most painful organic diseases, 
such as corroding ulcer, carcinoma, &c., may be thus exposed without inflict- 
ing the least pain, while any local treatment may be instituted without danger 
of injuring the healthy structures. By this method, also, a proper estimate, 
anatomically, can be had of the shape and capacity of the vagina; for where 
there is no organic change, no contraction, and no rigidity of it from sloughs, 
ulcers, and cicatrices, and where the uterus is movable, this canal immediately 
swells out to an enormous extent, thus showing its great expansibility. 

* Operative Surgery, Am. edition, vol. iii. page S51. 

t Cheliiis' Surgery, by South, Am. edition, vol. ii. page 191. 



1852.] 



Sims, Treatment of Vesico- Vaginal Fistula. 



65 



Fig. 1 represents the speculum. When introduced and held properly, it 
causes no pain whatever. It is well enough to have two or three of different 
sizes, so as to be prepared for any case. The one ordinarily used by me is 
about 2 J inches from a, where it supports the sphincter, to its terminal ex- 
tremity at h. Its concavity c, c serves to reflect a strong light down on the 
vagino-vesical septum, the seat of fistula. Its breadth from to e is about 
■g-ths of an inch, widening a little as it approaches the end, making it somewhat 
in the shape of a duck's bill. The handle is made strong and unyielding, 
because a considerable degree of leverage has to be exercised by it. The curve 
at fj being cushioned to prevent its hurting the forefinger, fits accurately 
over it. The whole instrument is made of German silver, the concavity being 
highly polished for reflecting the light. 



Fig. 1. Fig. 2. 




A small, slightly convex spatula. Fig. 2 (of German silver), may occasion- 
ally be needed to press the urethra downwards against the symphysis pubis, 
when there is a very minute fistula in the neighbourhood of the trigonus vesi- 



66 



Sims, Treatment of Vesica- Vaginal Fistula. 



[Jan. 



calis; particularly if the urethral folds are very redundant. This will seldom 
be used, but is sometimes indispensable, not only in exploration, but in hold- 
ing the healthy parts out of the way in passing sutures. 

These simple instruments, with this position and a good light, are all that 
are necessary for obtaining an accurate view of the parts. If the vagina and 
outlet are ordinarily capacious, a good strong northern light, of a clear day, 
from a large solitary window, is all-sufficient. But if this canal has been 
narrowed by cicatrices after extensive sloughs, or from other causes, then sun- 
light is absolutely necessary for every stage of the operation from first to last. 
For this purpose, a small table is placed near a window admitting the sun- 
light. An assistant, sitting by, adjusts on the table a glass. Fig. 3, some 
eight or ten inches in diameter, so as to throw the rays of light into the vagina, 
which, passing to the right of the operator, and striking the concave surface 
of the bright speculum, are reflected down on the anterior vaginal paries, mak- 
ing everything perfectly distinct. 

Fig. 3. ' Fig. 4. 




Fig. 4 shows the speculum introduced, elevating and supporting the sphinc- 
ter ; also the relative position of the organs, when the patient is examined as 
directed; the vaginal canal being distended to its greatest capacity. 

Of scarifying the edges of the fistulous opening. — This was the most 
tedious and difficult part of the operation with me, as it has always been with 
others. For three or four years, I had great trouble in getting such instru- 



1852.] 



Sims, Treatment of Vesica- Vaginal Fistula. 



67 



ments made as I thought indicated ; but those I now use for this purpose are 
so simple, that they can be had ^. ^ ^ 

anywhere. A delicate tenaculum, \_ ^ 

Fig. 5, a, and a sharp-pointed knife, 
Fig. 5, h, are alone necessary. 

The tenaculum. Fig. 5, a, is 
very small; the curve being at 
right angles with the shaft, and 
not more than one-third of an inch 
long. If longer, it is not easily 
managed, nor so generally applica- 
ble to any and every part of the 
fistula. The shaft, some five or 
six inches long, is set into a firm 
handle. Of this size and shape, 
it can be used to elevate the edge 
of the opening with equal facility, 
whether laterally or otherwise; 
while, if curved at more than a 
right angle, it can be useful only 
in hooking up and drawing for- 
ward the anterior and posterior 
margins. 

Fig. 5 represents the tenaculum 
a, hooking up and elevating the 
edge of a fistula, while the point 
of the knife h is applied, ready to 
separate the part so raised up. 
This process is continued till the 
edge of the opening is well vivified 
all round (as seen by the dotted 
line), sometimes removing a strip 
an inch or more long before it is 
cut or torn off. The denudation 
is to be from a quarter to the third 
of an inch wide. I have often 
made the mistake of not removing 
enough of the callous edge; but I 
now take good care to remove it 
freely, extending the scarification 
up on the vaginal surface. I do not remove any of the lining membrane of 
the bladder, unless it is very much altered in character, and projects through 
the fistula into the vagina in such a way as to obstruct the easy performance 
No. XLV.— Jan., 1852. 6 




68 



Sims, Treatment of Yesico- Vaginal Fistula. 



[Jan. 



of the operation ; which rarely happens, and only where there is a great loss 
of substance. 

Where the fistula is very small, say not larger than a common-sized probe, 
or even as small as a number seven or eight sewing needle, the best plan to 
scarify is, to hook up the part with the tenaculum, pull it forward, and by a 
thrust of the knife transfix the entire thickness of the vagino-vesical septum; 
then by a circular sweep of the instrument, the whole fistulous track may be 
removed at once; which substitutes for the small and callous opening, a 
smoothly cut orifice of rather a conical shape, large enough to admit the end 
of the forefinger. 

Where the fistula is so small, there is always an abundance of tissue, and 
there need be no fear of removing the parts freely; for it is easier to close 
properly an opening as large as the end of the finger, than a smaller one, pro- 
vided there is no scarcity of texture. 

Where the fistula, on the other hand, is very large, there is 
Fi?. 6. occasionally some trouble in determining exactly what to cut; be- 
cause by the bearing down, sobbing, straining, or even voluntary 
resistance of the patient, the mucous membrane of the bladder 
may be forced out in voluminous folds, so as to render the fistu- 
lous edges indistinct, and there is danger of scarifying, either too 
high up on the vaginal surface, or too far in on the vesical lining. 
To obviate this difficulty, a properly curved metallic bougie may 
be passed through the urethra up to the fundus of the bladder; 
thus putting the parts on the stretch and carrying back into its 
cavity, the apparently redundant lining. The bougie curved down 
between the thighs may be held by a third assistant. But I greatly 
prefer to introduce a bit of soft sponge, of proper size, into the 
cavity of the bladder, which forces back the lining membrane, 
leaving the fistulous boundary distinct, when the scarification may 
be easily accomplished. The introduction of the sponge into the 
cavity of the bladder, or merely between the edges of the fistula, 
as well as its removal, is always attended with very great pain. 
Once introduced, I allow it to remain, till the sutures are passed 
and ready to be secured. 

During the scarification, there is, of course, always hemorrhage; 
and, in some instances, it is so profuse as to compel us to desist 
for a short time, the patient being allowed to change her position 
and rest. As soon as the bleeding ceases, the operation may be 
resumed. 

To remove the blood from the cut surface during the scarifi- 
cation, a probang is necessary (Fig. 6), which is made by tying a 
nice bit of sponge to the end of a piece of whalebone some eight 
or ten inches long. It is well enough to have two or three of 
these, which will keep one assistant pretty busy to wash clear of 
blood at this stage of the process. The probang can generally 



1852.] 



Sims, Treatment of Vesica- Vaginal Fistula. 



69 



be best applied by the operator, as bis position allows him to see exactly 
where it is most needed. 

I cannot lay too much stress on the great necessity of perfecting well this 
part of the operation ; for, upon a proper and free denudation of the fistulous 
orifice, success or failure will mainly depend. 

Sometimes one edge of the fistula is thinner than another. Velpeau and 
others have noticed this fact; but in not a single instance have I found (as 
they did) the thinner edge behind and the thicker before. Where there was 
any appreciable difference, the reverse was the fact in every case that I have as 
yet examined. This thinning of the anterior edge, where it was right at the 
neck of the bladder, was always a serious obstacle to the proper closure of the 
fistula. By giving way too soon, it almost invariably left an opening at the 
point of its greatest thinning. This, however, is a peculiarity belonging to 
individual cases, and will be dwelt on more particularly when we come to 
describe them. 

Of the Suture Apparatus. — Sutures all serve the same general purpose, 
viz. the bringing and holding together parts that we wish to unite. They 
are variously named, according to circumstances — as the Interrupted, because 
it is solitary; the Continued, because a plurality of them are joined together; 
the Quilled, because of the peculiar method of securing it ; and the Twisted, 
for a similar reason. 

The one that I use for closing vesico- vaginal fistulse, I have termed the 
clamp suture, from its peculiar method of action. Thus, if the profession 
allow me to introduce a new suture by its most appropriate name, we shall 
then have in general use, sutures named, first, according to their relation, the 
interrupted and continued. Second, according to the method of securing 
them, the quilled and twisted ; and third, according to its method of action, 
the clamp suture. 

As all sutures are but modifications, one of another, so is the clamp a 
modification of the quilled. 

The clamp suture is composed of small annealed silver wire fastened to 
cross-bars, after the manner of the quilled suture. The wire is drawn down 
to about the size of a horse-hair, and then annealed. The cross-bars, or clamps, 
are very small, not more than a line in diameter, and made of silver or lead, 
as most convenient. If of silver, they may be tubular; when of lead, solid. 
They must be highly polished, and without the slightest asperity, particularly 
at their extremities. They act as clamps in this way. The parts embraced 
between them, being held in close apposition, swell upward, and overlap 
them; while they, by pressure, produce an ulceration in the vaginal surface, 
sufficient to allow of their being perfectly embedded, and after a while even 
sometimes hidden from view. This ulcerative process is attended, of course, 
with a purulent discharge, which, continuing for three or four days, diminishes, 
and soon ceases altogether; but not till the bed made by the clamp becomes 



70 



Sims, Treatment of Vesica- Vaginal Fistula. 



[Jan. 



lined with mucous membrane. After this the apparatus would lie innocu- 
ously in the tissue for an indefinite period. I have allowed it to remain 
long enough for the extremities of the clamps to be covered over completely 
by firm granulations, which, opposing considerable resistance to their removal, 
had to be lacerated before this could be accomplished. 

This suture is far preferable to anything before suggested for the purpose. 
Its introduction dates from June 1849, since which time I have had compara- 
tively little trouble in the treatment of the great majority of cases of vesico- 
vaginal fistula. Properly applied, this suture never ulcerates out, having always 
to be removed by means of scissors, hooks, and forceps. It may be allowed 
to remain intact for six, eight, or ten days, or even longer. If removed too 
soon, the delicate cicatrix may gradually yield to the traction of the ascending 
uterus, or to the force exerted by the bladder in expelling its contents, and 
thus reproduce a small fistulous orifice to be closed by a subsequent and more 
cautious operation. I have seen the new cicatrix give way from another 
cause, and perhaps it is the chief one. The clamps, burrowing in the vaginal 
surface, leave a deep sulcus or fissure on each side of the new cicatrix, which, 
when they are removed too soon, fill up by granulation. It is a law of all 
granulating wounds to contract as they heal, and this contraction on each side 
of the new cicatrix is often sufficient to pull it gradually apart. But if the 
clamps are allowed to remain till their sulci are covered with mucous mem- 
brane, then there is no danger of this accident, for these chasms then gradually 
disappear, less by filling up with granulations, than by an absorption of their 
elevated edges. 

Accidents of this sort have happened repeatedly in my hands, from a too 
early removal of the suture apparatus. Great judgment, which experience 
alone can give, is necessary to determine the length of time that the sutures 
ought to remain intact, for no positive rules can be laid down that will answer 
invariably in every case. 

I have also seen serious mischief result from leaving the clamps too long 
embedded in the parts. Their burrowing and ulceration may extend entirely 
through the vagino-vesical structure, thereby substituting new fistulous open- 
ings for the original one. This complication is by no means incurable, but 
only prolongs the treatment, and postpones ultimate success. 

In two or three instances I have witnessed a still more serious accident 
from an undue pressure of the clamps, viz. a strangulation of the enclosed 
fistulous edges, which unfortunately resulted in a sloughing of the tumefied 
parts, and a consequent enlarging of the opening. In no instance, however, 
has this accident rendered the case hopeless, or even caused me to feel any 
concern either for the immediate safety of the patient, or for ultimate success 
in treatment. 

After the scarification is completed, the patient is allowed to rest for a few 



1852.] 



Sims, Treatment of Vesico- Vaginal Fistula. 



71 



minutes, before the introduction of the sutures; an ope- 
ration which is somewhat tedious, but not difficult. The 
number of sutures will depend on the size of the fistula. 
Less than two will not suffice for the smallest opening; 
while the great majority of cases will require three; and, 
occasionally, we meet with one sufficiently large to de- 
mand four. 

The needle which I use is represented by Fig. 7. It is 
awl-shaped, and spear- pointed, with the eye near the point. 
The shaft is about six inches long; the part near the handle 
is made malleable, allowing it to be bent into any desirable 
shape for the purpose of preventing the hand, as it grasps 
the handle, from obstructing the view of the operator. 

To illustrate the method of suture, let us suppose a 
case, where the fistula is oval, transverse, occupying the 
has-fond of the bladder, about half way between the 
urethra and os tincse, in the mesial line, and large enough 
to admit the end of the index finger. This, in shape, 
size, and position, is altogether the most favourable case 
that can occur, both for a neat performance of the opera- 
tion, and for certainty of success. Such a fistula will 
require three sutures. 

Fig. 8 represents them introduced at proper intervals; 
the two outside ones passing within a fourth of an inch 
of the angles of the fistula. The middle one is first ap- 
plied. The needle, armed with a silk thread, is entered 
about half an inch anterior to the scarified edge of the 
fistula; pushed deeply into the vesical septum, without 
transfixing it; brought out just at the edge of the mucous 
lining of the bladder; carried across the opening; made 
to enter the opposite side at a point corres- 
ponding with its direction anteriorly, observing 
the same precautions in its course; while it is 
brought out on the vaginal surface about half 
an inch beyond the scarified part. 

The passage of the needle through the an- 
terior edge of the opening is easy enough ; but 
the loose and yielding nature of the posterior, 
renders some support necessary before it can 
be made to appear on the vaginal surface. For 
this purpose a blunt hook (Fig. 9, a) is placed 
flatwise, just beyond the spot at which we in- 
tend the needle to come out, thus making a fixed 
point for it, when it passes with great ease. 




72 



SimSj Treatment of Vesico- Vaginal Fistula. 



[Jan. 



Fig. 9, 5, shows the needle armed and passed as directed : the spear-point 
having emerged at its proper place on the distal side of the fistula, is sup- 
ported by the blunt hook, a, over which it rests. 

As soon as this is accomplished, the blunt hook is laid aside, and, a small 
tenaculum (Fig. 10, a) used to hook up the ligature which lies close by the 
side of the needle, b. There is sometimes a little delay in doing this, particu- 



Fig. 9. Fig. 10. 




larly if the parts are too contracted, or the light not good. In this case, the 
needle should be pushed an eighth or a fourth of an inch further on, and then 
retracted as much, when a little loop of ligature will be left, into which the 
tenaculum can be passed. (Fig. 10.) After this, the needle is to be with- 
drawn entirely, leaving the ligature in sitH, with its distal end or loop securely 
on the hook. The hook is then drawn out, and with it, of course, the ligature, 



1852.] 



SimSj Treatment of Vesica- Vaginal Fistula. 



Fig. 12. 



the two ends of which are now hanging from the vulva. The other ligatures 
are passed in like manner, observing the precautions 
already laid down.* 

In pulling on the distal end of the ligature, an- 
other expedient is necessary to prevent the cutting 
and pain, which would inevitably attend its passage 
over the posterior edge of the fistula. For this, a 
crescent-shaped fork (Fig. 11) mounted on a shaft 
of convenient length, is passed up, which, pushing the 
ligature above its furthest point of exit, serves the pur- 
pose of a pulley; when it (the ligature) can be easily 
drawn backward or forward by traction on either end, 
without inflicting the slightest injury on the part, or 
pain on the patient. 

Having now given directions for passing the liga- 
tures, let us suppose that we have introduced the 
three, or as many as we want. The difficult part of 
the operation is over, and we have only to substitute 
the annealed silver wires for 
the silk ligatures; which is 
the work of but a few mi- 
nutes. Take a piece of the 
wire twelve or eighteen inches 
long, making a small crook 
at one end so as to fasten it 
securely to one of the liga- 
tures. Fig. 12 shows the wire 
crooked and hanging to the 
end of the thread ; the other 
end of the thread being pull- 
ed on till it comes out, leav- 
ing the wire in its place. In 
the same way we replace the remaining silk ligatures with silver wire; both 

* The ligatures cannot always be introduced with as little trouble as in the case just 
supposed. For instance, when the loss of substance is very great, the fistula is so wide 
that the needle cannot be made to traverse both sides of it at once; hence, it becomes 
necessary to hook up the ligature as soon as the needle has pierced the anterior border 
of the opening; when it is withdrawn, re-threaded with the distal end of the same liga- 
ture, and passed through the posterior edge. In re-threading the needle, care must be 
taken to pass the thread through the eye from its upper or concave surface ; otherwise, 
when it is withdrawn, it will be found still hanging to the main thread that is stretched 
across the fistula, instead of slipping easily from its free end: which is a very awkward 
accident, inasmuch as the patient is subjected unnecessarily to the pain and delay of 
having it introduced again. 





74 Sims, Treatment of Vesico- Vaginal Fistula. [Jan. 



ends of wbich project from the vulva, the proximal directed downward, and 
the distal held upward. 

The next step is to secure them by means of the clamps. In Fig. 13 the 
wires are represented passed, the two ends of each brought out of the vulva; 

Fig. 13. Fig. 14. 




the distal a, a, a, to the left; the proximal h, h, h, to the right. The distal 
ends are passed through small oblong holes made in the silver or leaden bar 
c, to suit the distances between the points of suture at d, d, d. The wires 
may be fastened to the bar or clamp c, by being turned twice around it, or by 
being passed through a perforated shot and bent over it. This done, we now 
pull upon the proximal ends b hh, and, as a matter of course, the bar c is 
carried into the vagina, up above the fistala, and made to occupy a bed right 
over the orifices d d d. Here, the crescent-shaped fork is supplanted by a 
modification of it. Fig. 14, broad enough to serve the purpose of a pulley for 
all three of the wires. The next step is to pass another bar or clamp on the 



1852.] 



Sims, Treatment of Vesico- Vajinal Fistula. 



75 



proximal ends of the wires, and to push it along them into the vagina, till it 
occupies a position in front of the fistula, corresponding exactly with the one 
behind it. 

Fig. 15 shows the two clamps, one on each side of the fistula, and every- 
Fig. 15. • Fig. 16. 




thing ready for closing it. The proximal clamp is pushed up by the crescent- 
shaped fork, while the wires are held firmly, 
of the fistula into such close contact that it 
would be diflficult to enter a common sized 
probe between them. The force necessary 
for tightening the clamps will depend upon 
the judgment of the operator; not enough 
will allow the parts to gape, while too much, 
which is the most frequent fault, will pro- 
duce the bad effects formerly alluded to. 

A simple and perfect contrivance now 
serves to hold the clamps in their proper 
places. A small bird shot, perforated, is 
passed along each wire close against the prox- 
imal clamp; when, the wires being held se- 
curely, they are gently but firmly compressed 
by means of a long strong pair of forceps 
(Fig. 16), whereby they are made to perform 
the office of a knot in preventing the clamp 
from slipping off the wire. The wires are 
cut off about a fourth or eighth of an inch 
from the shot, and then bent over, which 
effectually prevents their slipping off. 

Fig. 17 shows the appearance of the fistula and suture apparatus after the 



This brings the denuded edges 
Fig. 17. 




76 



Sims, Treatment of Vesico- Vaginal Fistula. 



[Jan. 



operation; the edges of the opening in apposition; a clamp on each side of 
it; the flattened shot against the proximal clamp; the wires cut ofi* and bent 
over the shot, which protects the recto-vaginal surface against their sharp ends, 
as well as prevents their slipping. 

The operation, which may have lasted some twenty or thirty minutes, or, 
under any circumstances, not more than an hour, is now over; and our pa- 
tient is ready for bed, complaining only of fatigue from the constrained posi- 
tion. 

There is one peculiarity about the instruments, which greatly facilitates the 
operation. For instance, the tenaculum, the needle, the blunt hook, and the 
crescent-shaped fork, have their shafts made malleable, so that they may be 
bent in a direction to keep the hand of the operator below the axis of the 
vaginal canal, which preserves the line of vision unobstructed. 

Of the Catheter. — Surgeons have always felt that something more was ne- 
cessary to cure a case of vesico-vaginal fistula, than merely closing it mecha- 
nically. The urine has been the great cause of failure. To prevent its per- 
colation through the closed opening has been regarded, heretofore, as almost 
insuperable. The catheter was tried by all, but its frequent introduction had 
a direct tendency to disturb the healing process, and to hasten the mischief it 
was intended to obviate; while all attempts to secure it permanently in the 
bladder by any external contrivance has proved abortive. 

Desault used a large gum-elastic catheter, " fixed to an apparatus resem- 
bling a truss, by means of a movable silver plate, provided with an aperture 
for its removal."" Tying it to the hairs of the vulva, and other equally use- 
less expedients have been resorted to. 

According to Chelius, the operation of paracentesis vesicse was practiced by 
Wutzer, who, he says, had the greatest success in the treatment of this dis- 
ease, having cured three cases out of eighteen. He compliments the efforts of 
his countryman by saying, " That he has importantly contributed to perfecting 
the operation, and, by the addition of paracentesis vesicae, in order more com- 
pletely to draw off" the urine, has advanced considerably farther than his pre- 
decessors." 

Wutzer gives specific directions for puncturing the bladder above the pubes : 
after which a tube is to be introduced, and " fixed immovably by means of 
wing screws in the cleft of a previously well fitted belly girdle, after which, 
the patient should be carefully conveyed to a bed previously prepared, jaZacecZ 
on her belli/, upon suitably cut out leather cushions, and properly budded in it 
with suitable leather straps." I allude to this method of Wutzer, merely to 
show what desperate efforts have been made to prevent the urine from escaping 
through the fistula during the process of treatment. 

With me, as with others, this has been the most serious obstacle to the suc- 
cess of the operation; for, if a single drop of urine finds its way through the 



1852.] 



Sims, Treatment of Vesico- Vaginal Fistula. 



77 



Fig. 18. 



Fig. 19. 



fistulous orifice, it is sure to be followed by more, and thus a failure to some 
extent is almost inevitable. 

Knowing that something to draw off" the urine continually was absolutely 
indispensable to success, and seeing that all other operators had failed to 
secure a catheter in the bladder by any justifiable external means, I con- 
ceived the idea of contriving for this purpose, a self-retaining instrument. A 
sponge tent was the first thing suggested to my mind. I supposed, if a long 
narrow piece of sponge could be safely introduced into the bladder, that it would 
absorb the urine as fast as secreted, which, by capillary attraction, would 
pass along the sponge, and escape without coming in contact with the fistula. 
Accordingly, a piece of fine sponge some three or four inches long, narrow 
in the middle, larger at each end, with a strong silk thread passing through 
its whole length to prevent its being torn, or broken, was first used. (Fig. 
18.) Concealed in a bi-valve catheter, it was readily introduced, the middle 
portion c, enveloped in gold beater's skin 
lying in the urethra, the small flat end a, 
occupying the cavity of the bladder, while 
the larger extremity h, hung out between 
the labia. It acted the part of a syphon ad- 
mirably, every drop of urine passing through 
it; but unfortunately for my patients (two 
of whom were experimented on with it), it 
became encrusted and perfectly saturated 
with calculous deposits, rendering its removal 
painful, difficult, and even dangerous. This 
expedient, promising so much in theory, and 
performing so ill in practice, was necessa- 
rily abandoned. 

Following up the idea of a self-retaining 
apparatus, I next hit upon the following 
contrivance. I took a piece of gum-elastic 
bougie (No. 5 or 6), some four or five inches 
long, and made a longitudinal split an inch 
long entirely through it, beginning about a 
fourth of an inch below the rounded end. 
(Fig. 19.) A piece of silver wire, a little 

longer than the catheter, was passed along it and fastened neatly at its vesical 
or split extremity. Traction on the lower end of the wire caused the sides of 
the split to open (Fig. 20), which allowed the urine to pass off freely, while 
the bulging at a a held it securely in the bladder. This seemed, at first, to 
promise success, but after trying it in various cases for about twelve months, 
it, like its predecessor the sponge, had to be laid aside. There were several 



78 



Sims, Treatment of Vesica- Vaginal Fistula. 



[Jan. 




instead 



20. reasons for its failure. If made of a larger catheter than 
a No. 5 or 6, it would not open and close with regularity', 
and hence, would press unequally and injuriously on the 
fistula; whereas, when made of a No. 5 or 6, its calibre was 
not large enough to permit a free discharge of the muco- 
purulent secretion which always attends the use of silken 
sutures ; and this compelled its removal, at least two or three 
times a day, for the purpose of cleaning it out. Hence, its 
frequent introduction, with the consequent disturbance to the 
parts from the opening and shutting of the split end, inter- 
fered with the healing process to such an extent as to make 
it necessary to give up its use entirely. 

Foiled in this, I devised another instrument on the self- 
retaining principle. It was a large silver catheter, curved 
in opposite directions, giving it a sigmoid form (Fig. 21). 
The end a was carried up behind the symphysis pubis, the 
part c lay in the urethra, while the extremity h hung down 
between the nates. 

This was the first successful approximation to what was 
really wanted. When the patient lay on the back, the end 
h was lower than the base of the bladder, which made it 
literally a syphon; when she turned on either side, it had a 
semi-rotation that still kept the end a upward, while the outer 
extremity hung downward over the thigh, inviting the easy 
passage of the urine. 

To insure a free discharge of the muco-purulent secretion 
along with the urine, I made a long narrow slit on each side 
of the holes, as here represented. To see how the instrument would 



Fig. 21. 




answer, I introduced it into the bladder of a patient having a very large fistula. 
Feeling well satisfied with its performance, I attempted to remove it and found 



1852.] Treatment of Vesico-Vaginal Fistula. 79 

it impossible to do so. Folds of mucous membrane had projected into the 
fenestra, and thus locked it up in the bladder : they were disengaged by the 
finger passed up through the fistula. The two long openings were then closed 
and several round ones made, about the size of those represented. They 
were larger than in ordinary catheters, on account of the abundant tenacious 
secretion before alluded to. 

I operated on a case, and applied what I then supposed to be a faultless in- 
strument. Everything progressed well for five or six days, the catheter remain- 
ing in the bladder intact for that length of time; but now it became neces- 
sary to remove it for the purpose of cleaning out the mucus and urinary 
concretions that were obstructing the free egress of the water. But here I 
was foiled. 1 could pull it down for, perhaps, an inch, when it suddenly 
stopped; then by letting it go, it would slip back into the bladder with a sort 
of jerk. It evidently seemed to be fastened there by some means that I 
could not exactly comprehend. Every reasonable effort to remove it proving 
abortive, I, at last, pulled it out by main force. On its removal, the secret of 
its retention was explained by the shreds of mucous membrane (some an inch 
long) hanging from each orifice on the under and lateral surfaces of the .ca- 
theter. The long-continued presence of an instrument in the urethra, which 
was entirely too large for it, irritated and inflamed the lining membrane, and 
caused it to throw out granulations. These, with the granulations of the 
fistula, shot little granules through the holes in the catheter, which spread out 
into button-shaped knobs on its inner surface, thereby preventing its removal. 
The injury done to the part, and the pain inflicted on the patient, may very 
well be imagined. 

. This instrument was variously modified (always keeping in view the self- 
retaining principle); but it was not reduced to its present simple form until 
about three years after this. I will not detain the reader longer with a state- 
ment of the troubles and disappointments that were encountered before I got 
it perfected, particularly as it will be necessary, in giving the history of in- 
dividual cases, to speak of these amongst the causes of failure in some of the 
operations. 

The urethra in some women is less than an inch long, while in others it 
may be an inch and a half; besides, it may be so small in some, that a No. 5 
catheter is as large as can be borne with any degree of comfort, while others 
will take a No. 9 or 10, and retain it easier than one smaller. Thus, it is 
evident, that almost every case may require its own catheter, peculiar in 
length, diameter, and curvature. 

Fig. 22 is a correct representation of the self-retaining catheter, and exactly 
of the size and shape that is most generally required. It may sometimes be 
curved a little more. The end c is introduced and lodged up behind the sym- 
physis pubis; the part from a to & lies in the urethra; while the outer ex- 
tremity dj hangs down immediately below the meatus urinarius; this down- 
ward projection at d serves the double purpose of preventing it from slipping 



80 Sims, Treatmenf of Vesico- Vaginal F'lstula. [Jan. 

into the bladder, and of preserving its parallelism. If this part is too straight, 
running in the direction of the axis of the main channel from a to h, the in- 
strument, after a few hours' use, will revolve on its own axis, and the end c 

Fig. 22. 




may be turned to one side, or even so far round as to impinge on the fistulous 
opening. Should this accident happen, the instrument is not well suited to 
the case. It is either too long, too short, too crooked ; or, what is more likely, 
not curved down enough below the meatus. 

When well fitted to the case, it can be worn with great ease to the patient; 
and never turns, nor slips out, it matters not whether she lies on the back or 
side. It is perfectly self -retaining, being held in the bladder by an internal 
pressure against the symphysis pubis, and by an external pressure on the outer 
end exerted by the labia overlapping it, and hiding it entirely from view. 
The holes should be small, about as represented in the drawing. 

Thus, I have, as briefly as possible, described the mechanical apparatus ab- 
solutely necessary for the successful treatment of vesico-vaginal fistula. 

0/ the After- Treatment. — The operation finished, the patient is placed in 
bed, and the catheter introduced into the bladder. A moment will suffice to 
show the urine leaking from its outer extremity. 

A large anodyne should now be given, such as morphia, laudanum, pare- 
goric, or whatever we may know will best agree with the patient. The 
bowels are to be kept perfectly quiescent, till the success or failure of the 
operation is ascertained. I have often kept them locked up for three and 
four weeks without any bad consequences whatever to the general system. 
In but two instances, that I recollect, have I ever permitted them to be opened 
under ten or fifteen days from the time of the operation. This is very easily 
done. Previously to the operation some light laxative medicine must be 
given: after it, the diet must be of a constipating character. I generally 
direct my patients to live on tea and crackers, allowing cofiee if preferred, 
and prohibiting meats, fruits, saccharine substances, and all articles of food 
made of Indian, or common corn meal. Formerly, I allowed as little water 
as possible ; but latterly, since the introduction of silver sutures, and the per- 
fection of the catheter, I have not thought its interdiction necessary. To 
assist the diet in producing constipation I order some form of opium in as 
large doses as can be borne, at least twice in the twenty -four hours. Old 
fistula cases are generally used to opium ; and where they are not, they soon 
learn its beneficial efi"ects. It calms the nerves, inspires hope, relieves the 



1852.] 



Sims, Treatment of Vesico- Vayinal Fistula. 



81 



scalding of the urine, prevents a craving for food, produces constipation, sub- 
dues inflammatory action, and assists the patient, doomed to a fortnight's 
horizontal position, to pass the time with pleasant dreams, and delightful sen- 
sations, instead of painful forebodings, and intolerable sufferings. 

There is not the least necessity for the patient's assuming the erect posture, 
even for a moment : thus, by diet, opiates, and quietude, a perfect state of 
constipation can be kept up as long as we could possibly want it in any case. 
All this facilitates the healing process, which is effected by the " first inten- 
tion or, if it fail, it does so only at one or two points, which may be subse- 
quently closed. 

The catheter is to be removed as often as necessary to keep it clear of con- 
cretions and mucus, which, in a few cases, may be twice a day; in some, 
once; while in others, it may be allowed to remain two or three days, or even 
longer. It is to be carefully watched, and must not be permitted to remain 
long enough to become obstructed. I have seen a failure result from a neglect 
of this precaution. 

The patient's comfort is greatly promoted, by washing the vulval opening 
twice a day, or oftener, with warm or cold water, as may be preferred. 

For this purpose a common bed-pan is placed under the nates, as she lies 
on the back : when the water may be thrown into the os externum, over the 
mons, vulva, and inguinal regions, by means of a syringe holding some six 
or eight ounces. The water has sometimes to be thrown with considerable 
force to remove the urinary deposits from the nates and genitals. 

The patient may lie on the back, or on either side, changing her position 
whenever she pleases; but in no instance is she allowed to raise up in bed. 

Some women are more cleanly than others in protecting themselves and 
clothing from the urine. Most of them prefer old cloths to absorb it, which 
are changed as frequently as necessary for comfort. 

On the third or fourth day after the operation, I usually examine the 
sutures to see if all is right. This must be done with as little exertion on 
the part of the patient as possible. On the sixth or seventh, I examine them 
again, and if they are doing no mischief, it is much better not to remove them 
till the ninth or tenth day. The removal of the clamps is occasionally 
troublesome, but by a little care it can be done with sufficient ease to both 
patient and operator. The flattened shots are first clipped off, then by a 
blunt hook, the anterior clamp is readily elevated from its bed and removed; 
after which, the posterior one, with the wires attached, may be hooked up, 
pushed backwards, disengaged entirely, and then lifted out with the forceps. 

This accomplished, place the patient in bed again, and continue the use of 
the catheter, with the recumbent position, for several days longer, to prevent 
any strain or traction on the delicate new cicatrix. 

By allowing the patient i^o get up too soon, and evacuate the contents of 
the bladder spontaneously, there is danger of rupturing the cicatrix, but by 
persevering with the catheter and position, till it has time to become well or- 



82 SimS; Treatment of Vesico- Vaginal Fistula. [Jan. 

ganized, there is no danger. This will take usually fifteen days from the per- 
formance of the operation. 

In other parts of the body, most surgeons have witnessed the sudden dis- 
ruption or gradual yielding of a freshly cicatrized wound, which had been 
submitted to undue motion, or too strong distention. A case of this kind 
recently occurred in my practice. A negro woman (aged 27) had a small 
tumour on the dorsal aspect of the right thumb, involving the skin. It was 
removed by two transverse elliptical incisions; the edges of the wound were 
brought together and dressed with collodion, while the thumb was bandaged 
to a straight splint to prevent any motion in the joint or traction on the cica- 
trizing wound. It healed by the first intention; the dressings were removed 
on the seventh day, but the splint was continued on the palmar aspect of the 
thumb for seven days longer. It was then laid aside, as I supposed the 
cicatrix to be strong enough to resist the flexure of the thumb. Everything 
went on well for three or four days longer, when the patient, who was a 
cook, suddenly lifting a boiling pot from the fire, was alarmed by the snapping 
asunder of the cicatrix on the back of* the thumb, which made a noise so 
loud as to be heard all over the room. The cicatrix had burst open through 
its whole extent; the blood flowed freely and the woman was greatly frightened. 
It was dressed precisely as before ; it healed up as kindly ; and by preserving the 
same precautions for a longer time, the cicatrix remained permanently or- 
ganized, the skin in the neighbourhood yielding, and accommodating itself to 
the motions of the thumb as perfectly as it ever did before any loss of tissue. 
If such an accident as this can occur after eighteen days of cicatrizing, we 
need not be surprised at the gradual or sudden yielding of a cicatrix in the 
vagino-vesical structure in a shorter space of time. 

I have now completed what I have to say in a general way on the subject 
of the operation for vesico-vaginal fistula. It remains to detail individual 
cases, which will prove the curability of the disease, and also illustrate the 
varieties and complications to which it may be liable. The cases that occurred 
to me early and which were given to me for the sake of experiment, will 
show the difliculties that had to be overcome, the many disappointments that 
bad to be borne, and the ultimate success that crowned my efi"orts after the 
perfection of the mechanical contrivances ; which, as it will be seen, was the 
work not of a day, and the result, not of accident, but of long, laborious and 
persevering application. 

But this communication has already reached to such an extent that I must 
postpone the relation of my cases to a future opportunity. 



1852.] 



Meigs^ Remarhs on Atelectasis Pulmonum. 



83 



Art. Y. — Remavlcs on Atelectasis Pulmonum, or Im-perfect Expansion of 
the Lungs, and Collapse of the Lungs in Children; with cases. By J. 
Forsyth Meigs, M. D., Lecturer on Practice of Medicine in the Phila- 

• delphia Medical Association. 

Imperfect expansion of the lungs in new-born children^ and collapse of 
the texture of these organs subsequent to expansion, are two morbid con- 
ditions which have been studied and described only of late years; and which 
have not, as yet, received in this country the attention which they certainly 
deserve. 

The anatomical character of the lungs, described by the title of atelectasis 
pulmonum, or imperfect expansion, is found under two different conditions of 
things : 1st. As it exists in neonati, or young infants, who have never estab- 
lished completely the respiratory function ; and in whom, as a consequence, 
larger or smaller portions of the lungs have never been invaded and expanded 
by the inspired air; and, 2d. As it exists in those who have, at birth, accom- 
plished the respiratory act, but in whom, from some cause, acting at a longer 
or shorter time subsequent to birth, the texture of the lung has again col- 
lapsed, become impermeable to air, or, in other words, returned to its foetal 
or unexpanded state. 

This condition of imperfect expansion of the lungs is not, therefore, con- 
fined, as was at one time supposed, to new-born children alone, but may 
occur also at periods subsequent to birth, and in children who had fully and 
completely expanded the lungs at the moment of birth. Under the latter 
circumstances, the condition of the affected portion of the lung is one of occlu- 
sion, obliteration, or collapse, of the pulmonary tissue. 

The cases which follow are intended to illustrate the nature, causes, symp- 
toms, and mode of treatment of this interesting change in the pulmonary 
structures. 

The first case is one intended to show the effects that imperfect expansion 
produce in the neonatus. It is as follows : — 

Case I. Mrs. , a healthy, vigorous person, was delivered, after a very 

rapid and easy labour, at the full term of a pregnancy which had been natural 
and healthful in all respects, of a male child. The infant was of full size and 
stature, and perfectly well developed. It came into the world, however, pale 
and feeble, without cries, and without any of the strong muscular movements 
which usually attend the moment of birth. In consequence of its feeble and 
weak condition, and from the imperfect development of its respiratory func- 
tion, as indicated by short, rapid, and imperfect breathing, and the absence of 
cries, the cord was not severed until some moments after the birth ; not, 
indeed, until it was ascertained that there was no pulsation of the umbilical 
arteries at a short distance from the umbilicus. After the division of the 
cord the infant was rubbed with brandy, and then wrapped in warm clothing. 
Its respiration was very imperfect, the breathing being short, feeble, and, as 
No. XLV.— Jan., 1852. 7 



84 



MeigS; Remarlcs on Atelectasis Pulmonum. 



[Jan. 



before stated, entirely without cries. The colour of the surface was pale, and 
the extremities were cool, and the hands and feet bluish. The nurse was 
directed to keep the infant very warm, to place it in a position inclined to- 
wards the right side, as the one most favourable for easy respiration, and for the 
free action of the heart, and to keep it perfectly quiet. A few drops of brandy, 
in sweetened water, were directed to be given every half hour ; a weak lini- 
ment of hartshorn and sweet oil was applied, from time to time, to the thorax; 
weak mustard poultices were applied to the feet, and the temperature of the 
room was kept warm and even. No decided improvement took place in its 
condition, except that for a few hours the colour of the hands and feet became 
rather more pink than at first. The breathing was short, quick, and abdo- 
minal, there being scarcely any lateral movement of the chest. After about 
twelve or fourteen hours, the hands and feet became very blue, and, somewhat 
later, the cyanosed tint extended to the face and forehead. The breathing 
grew still shorter and more imperfect, the blue tint increased in depth of 
shade, and at the end of twenty-one hours from the birth, the infant expired. 

At the autojjsiy, the physiological development of all the thoracic and ab- 
dominal organs was found to be perfect.. The foramen ovale was still patulous. 
The lungs were, however, imperfectly expanded. The greater part of the 
lower lobes of hoih. lungs was of a dark-livid colour, depressed below the 
expanded portions, hard, non-crepitating, and not at all diminished in cohesive 
quality. On passing a blowpipe into the primary bronchus and inflating with 
the mouth, the depressed, hard, and dark-coloured portions at once rose to 
their natural level, became elastic, soft, and crepitating, or, in other words, 
expanded to their natural size, lobule by lobule, in the most beautiful manner; 
whilst, at the same time, their colour changed, under the influence of the 
entering air, from the dark and livid tint above described, to the rosy or pink 
tint of healthy pulmonary tissue. 

No signs of pneumonia, pleurisy, bronchitis, or tubercular deposit were 
observed in either lung. 

Remarhs. — In the case just detailed, the feeble state of the infant at birth, 
the symptoms exhibited during life, and the death, are evidently to be ex- 
plained by the failure to establish properly the respiratory function. The 
lungs had not, for some reason, expanded under the excitement of the atmo- 
spheric air. The only mode of accounting for this want of expansion is, by 
supposing that for some reason the muscular pov/er of the child was insuffi- 
cient to depress the diaphragm and to elevate the ribs to such an extent as to 
cause full and forcible inspirations. The vacuum, or rather the tendency to 
a vacuum, within the thoracic cavity, had not been sufficient to cause such an 
influx of air during inspiration as to overcome the contractile property of the 
lungs, and so cause a complete expansion of all the air vesicles, a large pro- 
portion of which had, therefore, remained empty of air, or, in other words, 
unexpanded. 

Now this deficient inspiratory power from feeble muscularity, cannot be 
sought for in any state of the infant determined during gestation, since the 
mother was strong and vigorous, the pregnancy healthy and natural in all 
respects, and the child properly developed. The only plausible explanation 
of it is one suggested by Dr. Pepper, who received the child at the moment 



1852.] 



Meigs^ Remarhs on Atelectasis Pulmonum. 



85 



of Ibirth, and who saw it with me afterwards, and assisted at the autopsy. 
This is, that the placenta had probably been separated from the uterus at too 
early a period of the labour — some moments, we will suppose, before the 
child entered the world — during which time, as the connection with the 
mother had been cut off, it is reasonable to believe that the vital forces of the 
child had been so much lowered, as to deprive it of the muscular strength 
necessary when it entered the outer atmosphere, to produce a full expansion 
of the thoracic cavity, and so to effect a dilatation of all parts of the lungs. 

The next case is one intended to show the effects of imperfect expansion 
on the health, when it exists to such an extent as to constitute a morbid state, 
without causing immediate or very early death. 

Case IT. — Mareh lltJi, 1850. I was sent for to visit a child just two 
months old, a girl, and born of very healthy parents. The infant was attacked 
yesterday with a slight dry cough, which continues to-day. The child looks 
bright and cheerful, with a natural and placid expression of the face, and 
presents no symptoms beyond the cough, and a slight hooping in the respi- 
ration. It nurses well and has no fever. Ordered two drops of sjTup of ipe- 
cacuanha to be given occasionally. 

12th. When I saw the patient to-day, at 11 A. M., I was shocked to find 
her looking dreadfully ill. The face was pale and dusky, the skin coolish, 
the breathing irregular, short, and frequent, the eyes half shut, and moving 
irregularly in different directions. Upon inquiry I was told that she had not 
seemed so wel] early in the morning as on the day before, and a small dose of 
castor oil had been given. It was the operation of the oil apparently that 
had brought on the condition above described. I administered instantly a 
few drops of brandy, and in half an hour the child seemed quite recovered 
from its exhaustion; it looked bright and intelligent, but still had slight 
wheezing in the breathing, and a quicker rate of respiration than natural. 
Ordered a quarter of a grain of alum to be given in syrup every two hours. 

loth. The night was quiet and comfortable, but at 9 A. M. to-day the 
infant began to look again very badly ; the face became pale and dusky, the 
hands and feet cold and bluish, and the expression languid and feeble. The 
respiration was short, irregular, frequent, and wheezing. There was some 
coryza, the nostrils being dry and slightly incrusted, causing thereby some 
obstruction and sniffling during the passage of the air in respiration. There 
was very little cough, and this was dry and short. 

I was much embarrassed at first as to the diagnosis of the case, it being 
quite clear that there must be something more than the slight coryza and 
bronchitis to explain the dangerous symptoms exhibited by the patient. My 
first thought was of intermittent fever, particularly as the parents resided in 
a malarious district, and as the mother had had chills while pregnant of the 
child, but this would not account for the excessive weakness, with the blue- 
ness of the hands and feet, and the short, irregular respiration. My next 
thought was atelectasis, and upon careful questioning I obtained the following 
information in regard to the state of the child at birth, and up to the time of 
my first visit, when it was, as stated, just two months old. 

The child was born in a feeble condition, so that the attendant was obliged 
to throw cold water upon it, and blow strongly into the face before respiration 
could be established. After these measures, however, it breathed well, with 
the exception that the respiration was rather short and frequent, and it cried 



86 



Meigs, Remarhs on Atelectasis Puhnonum. 



[Jan. 



loudly. For several days after the birth the hands and feet had a bluish or 
cyanosed tint, so that the accoucheur informed me that he watched the child 
with some anxiety during that time, and it was observed to breathe shortly. 
G-radually, however, the blueness passed away, and the child has seemed 
well since, except that the mother thought it always breathed rather short 
and imperfectly. It grew reasonably well, though at a less rapid rate than is 
usual, and decidedly less so than the previous children of the mother. 

I concluded that the case was one of collapse of the lung, occurring in a 
child who had had at birth imperfect expansion of the lungs, and in whom those 
organs had never been fully and completely dilated. The collapse depended, 
no doubt, on the impediment presented to full inspiration by the slight coryza 
and bronchitis, with which the patient had been attacked, and I believe, also, 
upon a disposition to periodical fever, received from the mother during gesta- 
tion. It has already been stated that the mother suffered from intermittent 
fever during her pregnancy. 

The coryza was treated by envelopiDg the head in a light flannel cap, and 
by passing frequently a small cameFs hair pencil, moistened with glycerine, 
into each nasal passage. Four drops of brandy were given in two teaspoonfuls 
of breast milk (the child could not suck) every half hour. A weak mustard 
poultice was applied to the front and back of the thorax, and a mustard foot- 
bath administered. 

In the afternoon the condition of the patient had improved very decidedly. 

I^th. Passed a very good night, nursing well several times. At 9 A. M. 
began again to flag very much, and at 11 A. M. looked very ill, the face being 
pale, and the forehead, hands, and feet deeply bluish. The nails especially were 
of a, deep-blue colour. At the same time the hands, feet, and arms were cold; 
the respiration was very frequent, irregular, sometimes gasping, and attended 
with considerable wheezing, owing to abundant dry and subcrepitant rales 
over the upper parts of the chest. There was but little cough, and it was 
short and dry. There was also much drowsiness, and no disposition to nurse. 
Coryza about the same. The brandy to be continued as may be necessary ; 
the nasal passages to be moistened frequently with a brush dipped into clear 
water, and at longer intervals with one moistened with glycerine. 

In the afternoon there was no improvement, except that the coryza was 
somewhat better. Believing that the case was, as above stated, complicated 
with a disposition to intermittent fever, I ordered an eighth of a grain of qui- 
nine to be given every two hours, in syrup and water; the brandy to be per- 
severed in ; the front and back of the chest to be gently rubbed every three 
hours with a liniment of amber oil and sweet oil, containing two parts of the 
latter to one of the former. 

Ibtli. Some improvement towards the afternoon, the colour of the skin 
being less pale and bluish, and the hands and feet warm. The inspirations 
are regular, and at the same time deeper and fuller. The cough, which has 
been very unfrequent hitherto, is now more frequent, stronger, and slightly 
loose. The subcrepitant rale continues. The pulse is fuller and stronger. 
The coryza is much better, so that the nostrils are quite clear. 

Continue the quinine every three hours, and give with it an eighth of alum. 
The brandy to be given as may be necessary. 

l^th. Patient continues to mend; cough strong, frequent, and loose; coryza 
almost well; temperature natural; colour very good. The act of nursing, 
which, on the 13th, 14th, and 15th, was very difficult, is now becoming easy 
and frequent. The alum and quinine to be continued as before. The brandy 
to be suspended. 



1852.] 



Meigs, Remarlcs on Atelectasis Pidmcnum. 



87 



Vlth and I'^th. The improvement continued. The respiration "was regular 
and easy, the cough frequent and loose, and there was much fine rale over the 
chest. The colour of the surface had become natural, except that it was still 
too pale; the temperature of the skin was sufficiently warm. The act of 
suckling was performed without any difficulty. 

The flannel cap was removed from the head to-day. 

l^tli. The child was well except a little cough, and some very slight and 
fine rale over the front of the chest. The alum and quinine were suspended, 
and one drop of syrup of ipecacuanha, one of paregoric, and two of sweet spirits 
of nitre, directed to be given every two hours. 

From the date of this sickness up to February 1851 (a period of eleven 
months), the subject of the above case continued to have very weak and im- 
perfect health. It had several attacks of intermittent fever, perfectly well 
marked, but of slight severity, and readily overcome by quinine or extract of 
cinchona. It had also for a considerable period a hard, dry, laryngeal cough, 
always brought on and exasperated by the act of deglutition. During this 
cough the fauces always presented a very red and roughened appearance, and 
the tonsils were much swelled and very red. The cough was treated with 
small doses of paregoric and syrup of ipecacuanha, and by touching the throat 
with a weak solution of nitrate of silver. Under this treatment, and with 
very warm clothing, and careful avoidance of cold and damp, the cough 
several times ceased, but would return upon the slightest exposure, and in 
spite of every precaution. There was also an attack of catarrh, but it vfas 
mild, and soon passed away. 

The mother continued to suckle the infant until it was about ten months 
old. It is proper to state, however, that during lactation it was necessary to 
give some additional food, which consisted, as it did also after weaning, of cows' 
milk containing wheat flour and a small portion of gelatine. Broths were 
also given at times. The quantity of food taken after weaning was generally 
large, amounting to three pints or two quarts per day, an amount quite suffi- 
cient to carry on abundantly well the development of most children at the 
same age. In spite of this, however, and of every advantage which the most 
careful hygienic treatment, and the most tender and unceasing watchfulness 
could supply, the growth of the body and mind were both very slow, so 
that, at the age of thirteen months, the infant was not larger, nor its intel- 
lect more developed, than in most hearty children at nine or ten months. 
But not only was it small in stature ; its limbs were very small and thin, 
and its muscular power feeble, so that it had never attempted to creep or 
walk, nor even to bear its weight upon the limbs. The lower extremities 
were very small, and had not strength sufficient to bear the weight of the 
body, as they instantly gave way on the attempt being made to cause the 
child to stand. Still there was no paralysis, as they were moved freely when 
the child was sitting upon the lap. During all this time, too, the respiration 
of the child was habitually short, high, and more frequent than natural, 
though not attended by any eff"ort. 

On the 9 th of February, 1851, the child was suddenly attacked with vio- 
lent, frequent, dry, and excessively painful cough, each spell of coughing 
giving rise to crying, and an expression of acute suffering on the countenance. 
Fever and quick and laboured breathing came on at the same time, and the 
case presented every symptom of severe illness. The diagnosis was pleurisy, 
though the disease could not be detected by physical examination at the first 
visit. On the second day, however, it was manifest that the attack was one 
of pleurisy of the right side, the percussion being dull over the lower part of 



88 Meigs^ RemarJcs on Atelectasis Pidmonum. [Jan. 

that side behindj the respiration feeble and slightly blowing, and there being 
a total absence of rales. 

After a few days the percussion became dull over the lower half of the right 
side, whilst over the same region there was absence of all respiratory sound. 
At the end of a week there was neither sonorousness on percussion, nor any 
sound of respiration, below the clavicle in front and below the upper part of 
the interscapular space behind. 

The case was treated at first by an application of dry cups over the right 
side, with minute doses of calomel, and with small quantities of paregoric to 
lessen the painfulness of the cough. 

The child soon grew very thin and debilitated, and lost all appetite. The 
acute symptoms subsided in great measure after ten days, though a hectic 
fever, with particularly well marked exacerbations every other day, continued 
up to the moment of death. 

At one time a slight improvement occurred in the state of the patient. 
The appetite returned somewhat; the nights were better; there was but little 
suffering, and the child was more comfortable. But the cough continued, 
though it was much less frequent. It also retained its perfectly dry, harsh 
character, there being not the least well marked looseness at any time. The 
breathing also remained short and frequent, though it was not so laborious as 
at first. During this time also the breathing exhibited the characters which 
are always well marked in collapse of the lung. It was almost entirely ab- 
dominal, there being scarcely any lateral movement of the chest. It pre- 
sented also the character described by Dr. Rees of London, which is a pecu- 
liar sinking inwards, or depression of the walls of the chest dimmg inspiration. 
This was perfectly well marked, and was so different from the movements of 
ordinary respiration as to draw attention the moment the lower part of the 
thorax was uncovered and inspected. 

The treatment after the cupping consisted at first of a blister, and at a later 
period in the use of liniments to the thorax, and still later in the application 
of diachylon plasters to the side. The internal remedies were extract of cin- 
chona, and iodide of iron in sarsaparilla syrup. The diet, after the acute 
symptoms had diminished, consisted of arrow-root gruel made with milk, and 
chicken soup. Brandy and wine whey were given occasionally, usually in the 
morning, prior to the febrile exacerbation. 

In March the child grew rapidly worse. It became very weak and pros- 
trate, and had frequent attacks of exhaustion. The cough was dry and 
troublesome, and the respiration laboured and frequent. It became much 
emaciated, and finally died on the 10th of the month (fourteen months old), 
after having had some slight convulsive movements. 

Autopsy. The right pleural sac was filled with thick, yellow, inodorous, and 
perfectly well concocted pus. The amount must have been about six ounces, 
though, as it was not measured, it is impossible to give a precise statement. 
The lung was pushed backwards against the side of the spine, and was flat- 
tened, dense, and entirely impermeable to air. 

The left lung presented in the inferior two-thirds of the lower lobe, all the 
appearances usually expressed by the term carnification. This portion of the 
lung was depressed below the level of the surrounding surfaces, and looked, 
therefore, smaller than the upper and expanded parts of the organ; it was of 
a livid or purplish colour, dense, hard, and non-crepitating on pressure. It 
did not break down under the finger, nor was it easily penetrable by the 
finger, as is the pulmonic tissue when really inflamed. The expanded por- 
tions were soft, elastic, crepitating, and of a healthy rosy colour. 



1852.] 



Meigs, Remarhs on Atelectasis Puhnomim. 



89 



On inflating the lung, by means of a blowpipe passed into the primary 
branches, the whole of the dense and livid part rose up gradually and slowly, 
lobule by lobule, to its natural size and level. It was a most convincing and 
beautiful demonstration of the real nature of the lesion. As lobule after 
lobule expanded under the repeated and powerful expiratory efforts of my 
friend, Dr. E. Wallace, who was making the examination, each part, as it 
dilated, resumed under the influence of the entering air, its healthy rosy red 
tint, and became at the same time elastic and crepitating. Dr. Wallace as- 
sured me that he was obliged to use a degree of force much greater than he 
ever employed to inflate healthy adult lung, and he succeeded only by several 
distinct and renewed attempts. I doubt not, therefore, from this fact, and 
from the marked density and compactness of the collapsed portion, that the 
lesion had been of long standing, probably from birth. 

The upper lobe, and the superior part of the lower lobe were quite healthy. 
They presented no trace of tubercle, nor any sign of pulmonic or pleuritic in- 
flammation. 

The heart was healthy, except a slightly patulous state of the foramen ovale. 
Abdominal organs healthy. 

Remarhs. — That the case just related was one of true atelectasis pulmonura 
there can be, it seems to me, no reasonable doubt. Some persons, after read- 
ing the above history, might be disposed to lay more stress on the intermittent 
fever, under which the child evidently laboured at times, than I have done. 
But, inasmuch as the child remained, at one time, for some months without 
any sign of periodical disease, and continued to exhibit during that period, the 
same characters of languor, feeble growth, and short, imperfect respiration as 
before, I cannot regard the intermittent fever as having any more influence 
over the health of the patient, than as tending, by its depressing influence on 
the vital powers, to keep up the state of constitutional debility under which 
the child laboured. 

I believe it to be highly probable that the infant never fully expanded the 
lungs after birth, and that the condition of collapse found in the left lung at 
the autopsy, had existed more or less completely from the moment of birth. 
I found this opinion upon the facts, that the child was so feeble when born as 
to make it necessary to stimulate, artificially, its respiratory movements; that 
its respiration was short, frecjuent, and rather imperfect, from that time; and 
that it presented, for some days after birth, the bluish tint and low tempera- 
ture of the hands and feet, which usually accompany imperfect expansion of 
the lungs ; and, that during the attack of bronchitis which it had had at the 
age of two months, it exhibited symptoms of exhaustion, of partial asphyxia, 
and of embarrassed respiration, more severe and threatening than could be 
accounted for by the amount of catarrhal inflammation present in the case. 
Moreover, the whole history of its life shows that it was labouring from the 
moment of birth, under some deep-seated, serious, and persistent disorder; a 
disorder sufficiently grave to impede the proper development of its physical 
and moral qualities, and to give to it at all times the appearance of a feeble, 
puny, and imperfect creature. Now, if disease of a serious nature' must have 



\ 



90 



Meigs, Remarhs on Atelectads Fulmonum. 



[Jan. 



been present, where did it lie? Not in the brain, for, though that organ could 
not be examined at the autopsy, it was clear that the disease was not there, 
from the fact that there had never been any disorder of the senses, any para- 
lysis, any deformity or distension of the cranium ] and, because, though the 
intelligence was dull, it was not absent, but merely imperfectly developed in 
consequence of the feeble development of the whole organization of the 
infant. The disease was not in the abdominal organs, since the digestive func- 
tion had always been well and regularly performed. Nor was it in the heart; 
for that organ was healthy, with the exception of a slightly open state of the 
foramen ovale, a condition always found in congenital atelectasis, and produced, 
or rather maintained, no doubt, by the obstruction to the pulmonary circula- 
tion caused by the density of a large portion of the parenchyma of the lungs. 
It must, therefore, have been in the lungs, as was supposed before death, and 
as was proved by the post- mortem appearances. 

Before quitting this case to pass to the next, I wish to call the attention 
of the reader, with some particularity, to one of the symptoms existing towards 
the close of the case. This symptom is one which I first saw described in an 
extract from a small work on Atelectasis Pulmonum, by Dr. Greorge A. Rees. 
It consists in a peculiar movement of the chest during inspiration. The walls 
of the thorax sink inwards, towards the mesial line, during respiration, instead 
of extending outwards as they do in healthy respiration. This falling or sink- 
ing inwards of the ribs during inspiration depends upon the fact that the vacuum, 
or rather disposition to a vacuum, caused by the descent of the diaphragm, is 
not filled up as it should be by a rush of air into the lung. On the contrary, 
the lung, being collapsed and inexpansive from the obliteration of its air-cells, 
cannot enlarge sufficiently to fill up the space left vacant by the descent of 
ih& diaphragm, and the walls of the chest are, therefore, driven inwards during 
the act of inhalation by the pressure of the atmosphere upon them. I'his de- 
pression occurs, not over the whole of the thorax, but at its base, about on a 
line with the muscular attachments of the diaphragm, so as to cause a kind of 
constriction or indentation at that point. The muscles, whose office it is to ele- 
vate the ribs, and to expand the transverse capacity of the thorax during inha- 
lation, still fulfil their office for the upper regions of that cavity, but are unable 
to lift the walls of the lower part of the cavity against the pressure of the atmo- 
sphere, when the space within can no longer be readily entered by the atmo- 
spheric air at the instant the vacuum is caused by the respiratory movement. 

In the case just related this symptom was very strongly marked, and gave 
to the thorax a very singular and striking appearance. The base of the thorax 
was indented, on both sides, by a deep gutter or depression, which remained 
depressed and unchanged during the inspiratory movements, or which, indeed, 
rather became more visible and distinct durinsi; these motions, so that the chest 
presented the curious spectacle of dilatation or expansion in its upper parts 
during inhalation, and of contraction or collapse at its base. 



1852.] 



MeigSj Remarhs on Atelectasis Puhnonum. 



91 



The following case is intended to show the symptoms which result from 
atelectasis, when it occurs subsequently to birth, the collapse of the air-cells 
taking place after they have been once properly expanded by the establish- 
ment of respiration. 

Case III. — The subject of this case was a boy, who, at birth, presented every 
appearance of health and vigour, and whose respiration was established fully and 
completely. The mother having proved an insufficient nurse with her previous 
children, a strong and healthy wet-nurse was procured. For two weeks every- 
thing went well, except that the infant had an attack of slight aphthous sore 
mouth, which, however, was passing oflP, when the nurse was suddenly seized 
with typhoid fever, and the child was weaned, and for a few days fed on artifi- 
cial diet. Puring these few days the aphthous sore mouth grew worse, and 
a diarrhoea consisting of loose spinach-green stools made its appearance. When 
the infant was eighteen days old, another wet-nurse was obtained. The infant 
took the new breast without any difficulty, but the diarrhoea, amounting to 
three or four loose stools a- day, continued, the mouth remained sore, and the 
child lost flesh. 

For a few days before the atelectatic symptoms were developed, the mother 
observed that the cry of the child was weaker than usual, so much so as to 
make her uneasy, though there were no other signs of sickness than what I 
have mentioned. On the twenty-fifth day after birth it was observed that the 
child coughed and sneezed several times, and had some stuffing in its breath- 
ing. On the evening of that day, owing to some accident, one of the gas- 
burners in the chamber, occupied as the nursery, was left open, and a sufficient 
amount of gas escaped to contaminate the air of the room. During that even- 
ing, the stuffing in the breathing above referred to continued, and the child 
slept more heavily than usual. At 9 P. M., it sucked as usual. Between 11 
and 12 o'clock, there was noticed a slight whistling, a kind of stridor, in the 
respiration, the skin became suddenly a little bluish, and a slight convulsion 
followed immediately. Several times between that occurrence and 4 A. M. of 
the next day, there were convulsive seizures, which were preceded and fol- 
lowed by deep blueness of the mouth, hands, and feet. The convulsive move- 
ments consisted in strong retractions of the head, in backward bending of the 
whole body, and in stretchings or extensions of the arms, whilst the fingers and 
thumbs were flexed into the palms. The under lip was drawn inwards; the 
whole mouth had a stiffened and unnatural look; the eyes were strongly up- 
turned. Towards 4 A. M., the infant slept easily without any movement, but 
there was a well-marked stridulous sound in the inspirations. Throughout the 
night the least disturbance of the child, lifting or nursing it, or changing its 
position, appeared to distress it, and sometimees brought on the convulsive 
attack. The least sound also, or a touch even, made it start at once. After 
some of the attacks it seemed to be dying, as it would lie pale and expression- 
less, and almost without breath ; in fact, its respiration was'sometimes entirely 
suspended for several moments. There was no vomiting and no stool during 
the night. The child had been heard to cough once or twice during the day, 
and had sneezed a good deal. There was no cough during the night. 

I was called to see the case on the following morning, Aug. 13th, 1849, 
at 7^} o'clock. I found the infant still very ill. The attempt to make it suck 
brought on a fit at once. In the attack (which resembled, I was told, those 
of the night before), the surface became bluish, the face and hands particularly, 
being very deeply tinted. The hands were cold. The respiration was feeble, 
imperfect; and slow, all the time; the inspiration was evidently partial, short, 



92 



Meigs, Remarks on Atelectasis Puhnonum. 



[Jan. 



and with very little power, and, just after the convulsive paroxysm, was en- 
tirely suspended for some seconds. 

No treatment beyond the use of a warm bath had been employed prior to 
my visit. The treatment directed by myself was as follows : three drops of 
brandy were to be given every half hour in two teaspoonfuls of breast-milk; 
the infant was to be comfortably wrapped in a number of warm blankets ; 
vessels filled with hot water were to be applied to the feet ; the child was to be 
placed on the right side, with the head and shoulders elevated; and, lastly, 
profound rest was rigidly enjoined. The infant was to be disturbed in no way 
except for the administration of the milk and brandy. Afterwards, as the 
administration of the brandy and milk brought on the convulsion, the doses 
were directed to be given only every hour. 

At 9 A. M., the administration of the milk and brandy brought on a violent 
spasm, attended with deep blueness. There were, however, in this paroxysm 
some loud cries, which were the first since the night before. At 10 A. M., 
the spasm was much slighter when the milk was given; at 11 A. M., it was 
still less marked, and unattended by blueness ; and at 1 P. M., there was no 
spasm, though three teaspoonfuls of the milk were given. The colour of the 
surface, at this time, was perfectly good, rosy red, and the palms of the hand 
pink; the hands were warm, and the ears naturally coloured. The expression 
of the face was placid and natural ; the contraction about the mouth, and the 
rigid indrawing of the lower lip, had disappeared. 

The treatment to be continued. 

August 14:th. — This morning the child looked drowsy and feeble; it had, 
when nursed, violent screaming spells, which were unattended, however, by 
blueness or convulsions, and I thought it much better. In the course of the 
day it roused up from its state of dulness, looked about intelligently and natu- 
rally, and, in the middle of the day sucked perfectly well, and, with the 
exception of weakness, paleness, and an expression of exhaustion, looked well. 

During yesterday, the whole face, the arms, and particularly the right arm, 
on which it had been lying, looked puffed and swelled. The right arm was 
unquestionably infiltrated with serous fluid, and that to a great extent, as it 
was very considerably swelled, and had the peculiar doughy, inelastic feeling, 
with slight pitting, which accompanies that condition. 

In the course of this day, after the violent screaming spells, and of course 
after the complete restoration of the respiration and circulation, all this swell- 
ing disappeared, and the child looked thin and delicate, as was to be expected 
after severe illness. W as not this the first stage, the beginning of the indu- 
ration of the cellular tissue or scleremia, which is so fatal in foundling hos- 
pitals ? 

After this time the child recovered its previous health gradually and 
steadily, and is at this moment (October 1851), a fine, healthy boy. 

Remarlis. — The case just described is interesting for several reasons, to wit, 
because it shows how suddenly the condition of atelectasis may occur in a 
child whose respiration previous to the attack had been quite natural. It 
shows that blueness of the surface, coming on suddenly in an infant, must not 
be supposed to indicate, in all cases, a defective structure of the heart ; and, 
lastly, it shows that a very simple treatment was successful in relieving the 
symptoms. 

The onset of the symptoms was, in this case, extremely sudden and unex- 
pected. The child was born at full term, and was in all respects healthy and 



1852.] 



Meigs^ Remarks on Atelectasis Pidmonum. 



93 



well developed. It is seized, however^ soon after birth, with slight thrush, 
and, just as that disease is passing away, the wet-nurse is taken sick, and it 
becomes necessary to employ artificial nourishment for a short time. The 
thrush now grows worse, diarrhoea sets in, the child loses flesh, and of course 
strength, and, though another nurse is procured on the eighteenth day, the 
cry of the infant is observed by the mother to be 'weak and feeble for several 
days before the atelectatic symptoms make their appearance. On the twenty- 
fifth day after birth, the patient is observed to have a very slight cough, and 
to sneeze several times; and in the evening it is seized suddenly with convul- 
sions, attended with marked cyanosed tint of the surface, and with short, 
imperfect, and slow respiration. 

Previous to this time there had been no sign whatever of cardiac imperfec- 
tion, and the period at which the foetal openings of the heart are usually closed, 
had long passed. It is impossible to suppose, therefore, that the symptoms 
depended on any admixture of the two kinds of blood. Nor is it possible to 
suppose that the obstacle to the circulation which caused the blue colour of 
the skin, could have existed in the heart, since there is no condition of that 
organ that could have caused so transitory an attack of cyanosis as this proved 
to be. The attack was not one depending upon gastric or intestinal irritation, 
as some might be inclined to suppose, since neither the thrush nor the diarrhoea 
present in the case, were sufficiently severe to give rise to such dangerous 
and repeated convulsive seizures as those I have described. Moreover, the 
convulsions were different from those usually attendant upon gastro-intestinal 
irritations; there was more stiffening and rigidity of the body and limbs than 
is commonly seen in the latter kind of cases; there was more blueness, and 
especially a more lasting blueness ; and lastly, there was greater derangement 
of the respiratory function. 

The case was evidently, it seems to me, one of atelectasis, in which the 
symptoms depended upon imperfect performance of the hematosic function. 
The child had been debilitated by the loss of its proper nourishment, and by 
the action, upon its economy, of an attack of thrush and diarrhoea. In this 
weakened condition it is seized with some slight, very slight, catarrhal symp- 
toms; the atmosphere which it breathes is for a short time impregnated with 
the gas escaping from a gas-burner carelessly left open by a domestic, and 
shortly afterwards portions of the lungs collapse, by which not only does a 
certain proportion of the blood fail to be oxygenated for want of a sufficiently 
extensive aerating surface, but there is occasioned a positive obstruction to 
the circulation of the blood through the lungs, and a consequent accumulation 
of black blood in the venous system of the body. Under this condition of 
things — deficient arterialization of the blood, and accumulation of venous 
blood in the nervous centres — it is evident that the functions of the nervous 
system must be imperfectly performed, the supply of nervous power must be 
insufficient, and we observe as results, irregular, imperfect, and convulsive 
muscular movements. So irritable does the nervous system become, that 



94 



Meigs^ Remarhs on Atelectasis Pidmonum. 



[Jan. 



convulsions are brought on bj the slightest disturbance or irritation^ as by a 
change of position, and by the effort of deglutition. 

The immediate cause of the collapse of the pulmonary vesicular structure 
waS; no doubtj the general debility of the child, and the obstruction to the 
entrance of air into the chest, occasioned by the catarrhal condition of the 
upper air-passages. That general debility often causes collapse of the lungs 
in young children, has been sufficiently proved by those who have studied the 
subject, since that morbid condition almost always occurs in subjects broken 
down by exhausting diseases, in those weakened by the action of unwholesome 
hygienic influences^ or in those who come into the world feeble and imper- 
fectly developed. Moreover, what can be more reasonable than the supposi- 
tion, that general debility will affect the muscular system by which respira- 
tion is carried on, as well as the other muscular systems of the body? And 
if so, it must follow that the act of inspiration, and consequently expansion of 
the lungs, produced by the muscular dilatation of the thoracic cavity, will be 
weak, feeble, and imperfect, in comparison with what occurs in health. 

Case IY. — In the spring of the present year I attended a lady in her con- 
finement, who gave birth at full term to a healthy boy, weighing between 
nine and ten pounds. The child was perfectly well in every respect when 
born, and gave us no disquietude up to the sixth day after his birth. On 
that day he cried a good deal in the morning. At one o'clock in the 
day he began to moan, and seemed distressed, so that the mother asked 
whether he was not ailing. Just before 2 P. M., whilst in the nurse's lap, 
he ceased moaning, became bluish, and seemed to lose his breath, so that 
the nurse thought he was dying. She immediately placed him in a warm 
bath, and sent for me. The bath restored his respiration, the blueness passed 
off, and he looked much better, though he continued to breathe irregularly 
and unevenly. A short time after this he again became blue, breathed 
slowly and irregularly, but had no spasm. A neighbouring physician was 
called in, and ordered a repetition of the bath, and a bottle of medicine of 
some kind. Shortly before four o'clock, P. M., I arrived, and found the 
child lying upon the lap of the nurse, and just beginning to have another one 
of the paroxysms which had caused so much alarm. The whole of the ex- 
posed surface, the head and neck, and the arms, hands and feet, were bluish. 
As I looked at the patient, the colour of the skin, especially that of the head 
and neck, became more and more blue, and at last almost black, so that the 
child looked more the child of a black than of a white woman. At the same 
time the head was drawn backwards and to one side by a tonic muscular 
spasm; the arms and legs were extended and rigid, and the fingers were 
flexed into the palms of the hands. The respiration was slow and imperfect, 
and the child seemed as though about to die in the convulsion. This condi- 
tion lasted for some moments, after which the convulsive state subsided, but 
the child remained bluish, and in a state of stupefaction. 

There was nothing in the history of this case that allowed me to refer the 
symptoms to any other cause than obstruction to the pulmonary circulation 
from collapse of the lungs, and, probably, a reopening of the foramen ovale 
from the congestion of the right side of the heart, brought about by the par- 
tial arrest of the current through the branches of the pulmonary artery. 
There was no derangement of the digestive function, nor was there any sign, 



1852.] 



Meigs, Remarlcs on Atelectasis Pulmonum. 



95 



even the least, of a catarrhal condition to explain the symptoms. I concluded, 
therefore, that the case was one of sudden collapse of some portions of the 
lungs, with consequent congestion of the right side of the heart, and, perhaps, 
reopening of the foramen ovale and admixture of the two kinds of blood. I 
told the mother that there was no indication for any medicine — that all we 
could do was to place the infant on its right side, on an inclined plane of 
pillows, in order to let the heart have full play, and to give every half hour 
a few drops of brandy in a teaspoonful of breast-milk. He was not to be 
disturbed from this position for several hours for any object whatsoever. 

My directions were accurately complied with. In a very short time the 
colour of the skin began to improve, and, though there were two slight 
paroxysms of convulsive stiffening, with increased depth of the cyanosed tint, 
between this time and the evening, I found the child much better in all 
respects at my evening visit. There was still, however, some blueness, with 
irregular, short respiration, and with a continuation of the dulness and in- 
attention. During the early part of the night, the breathing was short and 
uneven and attended with some moaning; but, about 4 A. M., these symp- 
toms disappeared, the child fell into a natural, easy sleep, lasting until 7 A. M., 
when it waked, nursed without any difl&culty, and seemed quite well. 

The child recovered perfectly, and is now (October 29 th) in fine health. 

Remarhs. — The treatment in this case was exactly the same as that em- 
ployed in the previous one. It consisted in the position on the right side, in 
perfect quietude, and in the exhibition of a few drops of brandy in breast- 
milk from time to time. No drug whatever was given, as there was no in- 
dication for the exhibition of any with which I am acquainted. The position 
on the right side, on an inclined plane, with the head and shoulders elevated 
at an angle of about 45°, and the absolute quiet maintained for several hours, 
constitute the treatment recommended, and often successfully practiced, by 
my father, Prof. C. D. Meigs, in cases of cyanosis neonatorum. Its good 
effects in these cases are supposed by my father to depend on the fact 
that the septum auricularum becomes, in this position of the body, horizontal, 
so that the blood in the right auricle must rise against gravity in order to 
pass through the foramen ovale; while, at the same time, the valve of that 
opening is disposed to fall down, by its own weight, and close the foramen, 
and is, moreover, pressed downwards by any blood that may enter the left 
auricle from the pulmonary veins. This explanation applies, of course, only 
to cases in which the cyanosis is supposed to depend upon the transmis- 
sion of venous blood from the right auricle, through the foramen ovale, into 
the left auricle. In the cases related above, the position mentioned was 
chosen because it is the one which seems most favourable to a full and easy 
performance of the respiratory and circulatory functions. The position towards 
the right side leaves the left side free and unembarrassed, so that the heart 
can act with the greatest possible freedom, while the partial elevation of the 
head and shoulders renders the movements of the chest much more easy and 
complete than when the body is lying on a plane surface. The perfect quies- 
cence so strictly enjoined is a very important part of the treatment, for I have 
always found that moving the child, shaking it, or dandling it upon the lap 



96 



Meigs, Remarlcs on Atelectasis Pulmonum. 



[Jan. 



(wliicli are tlie procedures generally employed by the nurse to bring it to), 
have only aggravated or kept up the alarming symptoms. Indeed, I have 
known the slightest movement, even the effort of swallowing (as in Case III.), 
to bring on convulsive movements. 

Collapse of the lung is met with, not only as a congenital affection, or as a 
post-natal one, occurring a few days or weeks after birth, but it has been 
observed in children of a much more advanced age. This latter is so important 
a form of imperfect expansion of the lungs, that I shall beg the reader's atten- 
tion to a few remarks upon it. 

It was not until the year 1844 that the frequency and importance of col- 
lapse of the lungs in older children was brought prominently before the medi- 
cal profession. In that year, MM. Legendre and Bailly published their 
researches on this subject in the Archives Generales de Iledecine. Those 
gentlemen have shown clearly that, in many cases of pneumonia and bronchitis 
in young children, a collapse of portions of the lung constitutes a most im- 
portant part of the diseased condition. They go so far, indeed, as to assert 
that nearly all the cases of so-called lobular pneumonia are, in fact, cases of 
bronchitis attended with collapse of a larger or smaller number of the lobules 
of the lungs. 

It is only necessary to read the later essays on the diseases of children to 
become convinced that a separate and distinct organic affection of the lungs 
has been heretofore confounded with pneumonia. This organic affection has 
been shown to be a true collapse of the air-cells, by the very simple experi- 
ment of inflating the lungs after death, under which operation the parts of 
the lung that are collapsed, and which have been heretofore supposed to be 
affected with lobular or lobar pneumonia, or chronic pneumonia, are seen to 
expand to their proper size and height, to lose their unnatural densit}'-, to 
regain their proper colour, and, in effect, to be restored, in some instances 
completely, in others partially, to their physiological and healthful characters. 
The peculiar character of the lesions constituting this affection had drawn 
attention for some time before it was properly understood. MM. Ptilliet and 
Barthez had described, in their article on pneumonia, a condition of the 
lung called carnification, which differed so much from ordinary pneumonia as 
to create a great difficulty in their minds as to its real nature. So much were 
they struck with its appearance that they were on the very verge of detecting 
its real nature ; in fact, the}^ did suggest its real nature, but were so possessed 
with the idea that it must be the result of some inflammatory action as to 
neglect to pursue their own suggestion, and to endeavour to explain the con- 
dition on the ground that it was ^^one sort of termination of pneumonia or 
chronic pneumonia.'' The following passage, quoted from their first volume, 
page 74, will show how closely they approached the truth: "The first idea 
that enters the mind on examining this tissue (carnification) is, that it resem- 
bles the lung of a foetus that had never breathed; we would be inclined to 
say that the pulmonary vesicles had not yet been dilated under the influence 



1852.] 



Meigs, Remarks on Atelectasis Puhnonum. 



97 



of the thoracic expansion, and had not, therefore, admitted air into their inte- 
rior. Or, rather, it would seem as though they had been obliterated after 
some attack of disease, perhaps of inflammation, without, however, remaining 
engorged, and after having lost the power of dilatation/^ I might cite other 
authors who have been struck with the peculiar anatomical appearances met 
with in many supposed cases of pneumonia and bronchio-pneumonia in young 
children, but am prevented by the want of space for greater detail. 

The lesions found in collapse of the lungs in older children, are much the 
same as those already described in the accounts of the above cases. As this 
condition of the pulmonary texture has, however, often been mistaken for pneu- 
monia, I will mention here the more important distinguishing features of the 
two alterations. In the-first place, the lung presents a different aspect externally ; 
in atelectasis the altered portion is smooth and shining, and is depressed below 
the general surface, so that it has a shrunken appearance, and it is of a purple 
or violet colour; in pneumonia, the surface is dull and often roughened by 
pleuritic inflammation, it is of a brownish-red colour, and, instead of being 
diminished in volume, is distended. In atelectasis the tissues retain wholly, 
or in great degree, their natural cohesive qualities; they are not readily pene- 
trable by the finger, nor are they easily torn, whilst in inflammation they are 
softened, friable, and easily torn or crushed. In atelectasis, the cut surface 
exhibits no granulations. In pneumonia, the granulated appearance of a cut 
surface is constant. Atelectasis is usually found in both lungs ; pneumonia, 
except in the true lobular form, is nearly always confined to one. The second- 
ary lesions of pneumonia, the pleuritic and bronchial inflammations, are absent 
in atelectasis, except where the latter occurs, as it often does, in connection 
with, and as a complication of pneumonia and bronchitis. And, lastly, in col- 
lapse the altered portion can be more or less completely inflated by artificial 
means; whilst in inflammation the hardened and altered parts resist all attempts 
at inflation. 

The most important matters for consideration in a practical view of this form 
of collapse are its causes, symptoms, and mode of treatment. 

Its two chief causes are general debility, and the existence of an obstruction 
to the entrance of air into the vesicular structure of the lung. A child who 
is either born weak and feeble, or who becomes so in after years, from ex- 
posure to unfavourable hygienic conditions, or from attacks of exhausting 
diseases, loses the muscular power which is necessary to effect a complete and 
efficient dilatation of the thoracic cavity; the inspirations, under these circum- 
stances, are short and imperfect, and the portions of lung most distant from 
the principal air-passages, not being reached by the inspired air, remain in an 
unexpanded or collapsed state. 

The other cause referred to, the existence of an obstruction to the entrance 
of air, occurs in bronchitis, bronchio-pneumonia, and pneumonia, in which 
diseases the presence of morbid secretions in the bronchia must impede more 
or less the transit of the inspired air through those tubes. But it is probable 



98 Meigs, Remarks on Atelectasis Palmonum. [Jan. 

that this result is seldom produced so long as the muscular actions of respira- 
tion retain their full force and vigour. When, however, these actions are en- 
feebled and diminished in force by a state of debility and prostration, it is easy 
to understand that the more distal portions of the vesicular texture of the lungs 
will fail to receive their due proportion of air; since there will here be two 
conditions at work to bring about this result : namely, an impediment in the 
air-tubes, and a deficiency in the power of inhalation. 

The most important symptoms indicative of the presence of this kind of col- 
lapse, are the sudden occurrence of short, high, and rapid breathing, with 
dulness on percussion, feebleness of the respiratory sound on auscultation, and 
with more or less mucous or sub-crepitant rale. At the same time the general 
symptoms are those of exhaustion and want of action, rather than those which 
accompany pneumonic or bronchial inflammation. When the collapse occurs 
in the course of bronchitis or pneumonia, there will be a sudden increase of 
the dyspnoea, and a development of asphyctic phenomena, without a correspond- 
ing increase of the febrile symptoms. I have met with several cases in which, 
after the symptoms of bronchitis or pneumonia have subsided at the usual time, 
and the patient has improved for a while, the above symptoms have made 
their appearance; the breathing has become again rapid and oppressed; the 
surface has become pale, or slightly bluish, and cool ; the cough has remained 
stationary or even diminished in frequency; and the child has grown dull, 
heavy, and inattentive. Formerly I was often very much at a loss to explain 
the symptoms; of late years, however, I have not hesitated to regard such 
cases as instances of collapse brought about by the state of debility following the 
primary acute attack, and have found them to recover under the administration 
of brandy, Huxham's tincture of bark, nourishing diet, and the use of mus- 
tard applications, or stimulating liniments, to the surface of the chest. 

A consideration of the causes of this kind of collapse, and of the symptoms 
which accompany it, will at once point out its proper mode of treatment. The 
state of general debility on which it depends, the pale, slightly asphyctic tint, 
and coolness of the cutaneous surface, the muscular weakness, the frequent 
and feeble pulse, and the drowsy inactive condition of the intelligence, all 
mark at once the necessity of withholding exhausting modes of medication, 
and of resorting to stimulants, tonics, nourishing diet, and the different kinds 
of rubefacients and mild revellents. The patient should be put upon the use 
of small doses of brandy, of tincture of bcirk, or of quinine, and upon a diet of 
milk and broths ; while, at the same time, the surface of the thorax ought to 
be gently irritated by applications of mustard poultices, or by frictions with 
hartshorn or oil of amber, and sweet oil. 

The following case is intended as an illustration of the above remarks upon 
the form of collapse of the lung occurring in children beyond the age of early 
infancy. 

Case Y. — I was called, on the 13th of February, 1849, to take charge of 
a child who had previously been under the care of another physician. The 



1852.] 



MeigS; Remarhs on Atelectasis Ptdmonum. 



99 



patient was a girl between two and three years of age, born of healthy parents, 
both of whom were living, and were in affluent circumstances. The child 
had been brought up at the breast, and had been hearty and strong, with the 
exception of an attack of dysentery at the end of the first year, until the date 
of the present sickness. A little more than two months before my visit, the 
illness began with an attack of pneumonia, in the early part of which there 
had been a violent convulsive seizure, followed by very dangerous illness last- 
ing for many days. The child then slowly and gradually got better ; remain- 
ing, however, very weak, pale, short of breath, without appetite, or with a very 
capricious one, and with frequent cough, up to the date of my first visit. 

Some time before my first visit, other children in the house had be(3n at- 
tacked with hooping-cough, and it was then suspected that the subject of this 
case was being seized with that disease. I found her in the following condi- 
tion : There was very little heat of skin, generally none, and often the surface 
was too cool and moist; the pulse was frequent, from 140 to 150, and soft 
and compressible; the respiration was frequent, but varying a good deal, 
and yet not laboured. The child was weak; she would walk slowly from 
chair to chair, but never ran about, and soon became tired and exhausted. 
She was very pale, white, except that now and then a slight hectic flush glowed 
upon the cheeks for a few hours. The least exercise caused rapid and violent 
action of the heart, and often occasioned free perspiration. There was a fre- 
quent, strong, catarrhal cough, especially at night. This cough was sometimes 
hard, at others loose, and was unattended by obvious expectoration. The 
appetite was very capricious, and the quantity of food taken small. The bowels 
were loose, there being from two to four stools a day; the dejections were thin, 
soft, and of a dark-brown colour. The temper was irritable, and the child 
difficult to manage, causing great difficulty in the administration of remedies. 
The nights were restless, the sleep being broken both by mere jactitation, and 
by coughing, which latter was often very troublesome. 

Auscultation revealed loud sub-crepitant rale, all over both sides behind, 
and particularly over the left. On the left side the respiratory sound was more 
feeble than on the right, and over the same part there was some bronchial 
respiration. The percussion was much duller on the left than on the right 
side. 

The treatment directed was twenty drops of brandy three times a day ; twenty- 
five drops of paregoric every night, to be repeated if necessary; and the diet 
to consist of milk, hard gingerbread (she would take no wheat bread, or 
any kind of pap), oysters when she would take them, soup, and ice cream. 

By the 22d, the cough had assumed all the characters of pertussis, with 
the exception of the hoop; the appetite, which had been capricious, was now 
feeble, the child refusing everything but about two to four ounces of milk a 
day, two or three small ginger cakes, and sometimes three or four oysters; 
no meat, or bread, or rice, or eggs, could she be induced to take. On the 
20 th, I ordered a grain of quinine to be given three times a day, and a 
large mustard poultice was to be applied to the chest every morning and 
evening. 

23(i. — Patient mending; has had a very good night; looks better, and 
has at times a slight tinge of colour in the cheeks, and is a little stronger. 
Respiration continues very frequent (50 to 60), and accompanied by a dis- 
tinct rale all the time; skin cool and moist; a little more appetite; bowels in 
better order, there being but two stools daily, and those more natural; takes 
the brandy pretty well; the quinine causes sick stomach; physical signs as 
before. 

No. XLY.— Jan., 1852. 8 



100 



Meigs, Remarks on Atelectasis Pulmonum. 



[Jan. 



To continue the mustard applications, the brandy, and the diet as above. 
R. Liq. ferri iodid. gtt. xlviii; syrup, sarsap. comp., aquas fluvial., aa 
^iss. M. A teaspoonful every two hours. 

March 1st. — The case has been going on pretty well since the last note. 
The hooping-cough has been slowly aggravating, but, notwithstanding, the 
strength has not diminished, and the appetite has been rather better. The 
oppression has been about the same ; so also the pulse. The surface has 
continued pale usually, eoolish, and disposed to perspiration, especially upon 
any exertion. The stools number, generally, two a day. Percussion as be- 
fore ; much sub-crepitant rale over the whole dorsum of the chest. 

Yesterday the child was taken out of the room and down stairs for the first 
time. In the evening, she was not so well; the pulse rose to 150 ; the respi- 
ration was 50, short, and attended with much wheezing; the cough was 
troublesome, the paroxysms being frequent and violent. This morning, at 
half-past five o'clock, the nurse observed her to be moving about in bed, and 
moaning, as though about to cough, when, suddenly, she was seized with a 
slight convulsion, in which the eyes were rolled upwards, the body and limbs 
became stifi", and she was entirely unconscious. The attack lasted but a few 
moments, and when I saw her half an hour afterwards, there was no trace of 
muscular agitation. She was sleeping deeply, but with entire quiescence. 
The respiration was about 70, the pulse 160, the surface very pale, and the 
expression that of languor and exhaustion. 

The mixture given above was suspended, and the following one ordered : — 
R. Ammoniaci ^ss; assafoetidse grs. x; pulv. acaciae 5ii; sacch. alb. 
aquae menth. virid. ^iv. M. A teaspoonful every two hours. The mus- 
tard application was also suspended, and from fifteen to twenty drops of the 
following liniment were to be rubbed over the inter-scapular space three times 
a day. R. Veratriae grs. v; ol. olivae, ol. monardae, acet. opii, aa ^i. M. 

There was no return of the spasm through the day, though the kinks of 
•cough recurred several times with much violence. At 2 P. M. she was 
awake, looking about naturally, and with perfect intelligence, without heat, 
but with a good deal of perspiration. The pulse was 144, and the respiration 
50. She ate a small piece of gingerbread, but would take nothing else. To 
take five drops of syrup of ipecac, in each dose of the ammoniac mixture, 
through the night. 

^d. — A bad night, with great restlessness, and frequent, hard cough. 
In the morning the pulse was 150, and compressible, and the skin hot, but 
not flushed. The respiration varied between 90 and 104, with much wheez- 
ing. While the pulse and respiration continued so frequent, the child was 
drowsy, and slept for three hours without coughing. No thirst at this time. 
In the afternoon she became somewhat roused, and in the evening seemed 
better, the respiration having now fallen to 84, while the pulse continued as 
before ; one stool to-day. Has eaten nothing but two ginger cakes, and has 
taken no drink, except a little water. Continue the remedies, except the 
syrup of ipecac. 

3(i. — Not much change. 

4:th. — Has had a very good night, sleeping quietly for an hour at a 
time, without much heat of skin. To-day was passed very comfortably, there 
being a coughing spell only about once an hour; more appetite. 

In the evening I found her sleeping quietly, with the respiration at 48, 
very quiet, more regular than before, and with much less rale; the pulse was 
148, soft, and regular; the skin natural. 

Continue the mixture and liniment; a diachylon plaster to be applied over 
the sternal region. 



1852.] 



Meigs, RemarJcs on Atelectasis Puhnonum. 



101 



*lth. — On the 5th and the 6th not so well, the pulse having risen to 150 — 
160; the breathing to 60 and 70: there was no appetite, and much rest- 
lessness. On the 5th, the ammoniac mixture was suspended, and the follow- 
ing prescription substituted: — R. Pulv. Doveri grs. iii; aluminis grs. vi. M. 
In chartulas No. vi — one to be given in the evening, and repeated if the 
cough should be troublesome. 

To-day the child is better; the pulse is 136 during sleep, soft, and regular; 
the respiration 48 to 50, easy, and with less rale than usual. Yesterday and 
to-day she has eaten more than before, taking a great deal of calves'-feet jelly, 
and some ice cream, besides gingerbread ; more cheerful ; only one stool 
daily, and that natural. The hooping-cough not more severe, and the 
catarrhal cough (which has continued between the hooping-cough kinks) less 
harassing and less frequent. The patient has become quite thin, and yet 
does not present the emaciation of tuberculous disease : one of the powders 
in the evening procures a very good night. For the last two days she has 
been obliged, by firm persuasion and some insisting, to take more food than 
hitherto, and this by my urgent advice. 

To continue the powders, liniment, and diet. 

l^itJi. — Decided improvement since last note. She has been ohliged since 
then to take food, under which method her appetite has improved, until she 
has now been taking for several days an abundance of nourishment; at break- 
fast from ten to twelve oysters, and at dinner sweetbread and rice. She has 
eaten during the last three days some bread and milk also, for the first time 
in six weeks. The colour of the surface has improved, the palms of the 
hands showing a faint pink tint, and the cheeks a slight tinge also. The 
strength is better also, and the temper cheerful. No fever in the last two 
days, whilst before this there had been every day some hectic flush and heat 
in the afternoon and evening. The nights have also improved, being now 
much more quiet, and disturbed only by the cough. The catarrhal cough is 
now very rare; the hooping-cough spells number from eighteen to twenty-four 
in the day; much less wheezing in the respiration. This morning, during 
sleep, the pulse was 116, of good volume, steady, and regular; the respira- 
.tion was 30, easy, and regular. On the 12th, the percussion was still dull 
over the upper two-thirds of the left side behind ; over the lower third it 
was flat ; in the same region, the respiratory sound was feeble, slightly blow- 
ing, and intermingled with mucous, sub-crepitant, and sibilant rales. Over 
the right side behind, the percussion was natural, and the respiratory sound 
full, but mingled with mucous and sub-crepitant rales. The rales were, how- 
ever, much less extensive and abundant than before. 

During the last two days the bowels have been opened but once in the 
twenty-four hours, the stools being natural. 

On the 9 th, a weak Burgundy pitch-plaster was applied over the posterior 
and lateral portions of the left side, below the axilla. The diachylon plaster 
and the liniment were continued. On the 10th, the patient was ordered two 
drops of the liq. ferri iodidi, three times a day. The Dover's powder and 
alum still to be given every evening ; diet of bread and milk, gingerbread, 
meat, sweetbread, oysters, jelly, ice-cream, rice; the articles given each day 
to be varied as the child might fancy; potatoes were forbidden. 

April dth. — The case has been going on well since the last note. On the 
7th, the child was taken out for the first time, the weather being warm and 
dry. To-day I found her running about the room in excellent spirits. She 
bears exercise much better than before, though it still makes her breathe 
quickly. During sleep the respiration has been as low as 24; pulse excel- 
lent; skin natural; tongue clean; appetite good; the food consisting chiefly 



102 Meigs, Remarhs on Atelectasis Piilmonum. [Jan. 



of oysters and sweetbread, gingerbread, and some bread and milk at break- 
fast and tea. The bowels are generally regular, though still somewhat in- 
clined to feculent diarrhoea. The cough is rare, and the hooping-cough has 
nearly disappeared. 

Auscultation reveals a natural vesicular murmur all over the right side be- 
hind, except that there is a slight expiratory sound over the middle and lower 
portions. Over the left side it is different ; above the spine of the scapula 
the murmur is perfect; over the middle third the respiration is still rather 
rude, and there is well-marked bronchial expiration; over the lower third, I 
could hear, at the termination of the inspiration, a fine sub-crepitant rale. 
The percussion is natural over the right side. Natural above the spine of the 
left scapula, it becomes duller below that line, and over the lower fourth is 
very dull. 

The plasters were removed five days ago. The iodide of iron to be continued. 

April 17th. Constantly improving. Growing fat, and obtaining a clear, 
good, and ruddy tint in the cheeks. Appetite good ; strength much greater. 
Respiration still hurried after exercise. The cough has nearly ceased. The 
percussion has greatly improved over the diseased side ; over the upper half 
of that side it is as clear as on the right, while over the lower half it remains 
yet a little dull. Auscultation reveals a clear and soft vesicular murmur, with- 
out prolonged expiration, over the upper half of that side; over the lower half 
there is still some expiratory blowing, and an imperfect vesicular murmur. 

Takes nothing now but the iodide of iron. 

Nov. 26th, 1849. I saw the child to-day, looking remarkably well. She 
has grown in height, and is stout and fat, with a fine healthy complexion. She 
is perfectly well to all appearances. Percussion yields a cJear and unusually 
sonorous sound over the dorsal region. The vesicular murmur, in the same 
region, is full and strong. 

A'^ov. 18-51. The subject of the above case continues to enjoy good health, 
with the exception that she takes cold somewhat more readily than most 
children. 

Remarks. — I cannot doubt that the above case was one of bronchitis, com- 
bined with collapse of some of the lower portions of the left, and perhaps of 
some lobules of the right lung, at least after it came under my charge. 
Prior to that, it is altogether probable that the case was one of pneumonia. 
The debility which followed the acute symptoms that characterized the early 
period of the attack, the nature of the general symptoms, the course which 
the disease followed, the nature of the physical signs, and the good effects 
obtained from the stimulating treatment pursued, all convince me that the 
thoracic lesion was a chronic bronchitis accompanying, and probably in part 
causing, a collapse of a considerable portion of the lower lobe of the left, and 
of a much smaller portion of the right lung. 

The most important point in the treatment was evidently the introduction 
of nutriment. This was effected by the use of stimulants and tonics, which 
tended to arouse the dormant digestive energies, and by obliging the patient, 
for a few days, to swallow considerable quantities of nutritious matter. To 
accomplish this, it was necessary to use partly actual force, and partly the 
most urgent entreaties and persuasion. The decided improvement in the case 
began from the time this plan was adopted; prior to that it had been 
stationary, or rather retrograding, for a space of about two months. 



1852.] MorlancI, Extracts from Soc. for Med. Improvement. 



103 



Art. YI. — Extracts from the Records of the Boston Society for Medical 
Improvement. By WiVl. W. MoRLAND, M D., Secretary. 

June 23.* — Psoriasis Guttata Syphilitica. — Dr. DuRKEE reported the case 
and exhibited the patient to the Society. — The above eruption appeared first 
upon the head, about three months ago; (patient was shown at the meeting 
in evening of June 2od, 1851;) other parts were affected with it in the fol- 
lowing order, viz : the face; the upper portion of the chest and back; the 
nates ; the palmar surfaces of the hands and the plantar surfaces of the feet. 
Dr. D. believed its appearance sufficiently declared its syphilitic nature ; and 
in this opinion the other medical gentlemen present concurred. The fauces 
were inflamed^ and several superficial ulcerations existed about the mouth. 
The patient stoutly denied having ever had any of the primary symptoms of 
syphilis. Dr. Durkee mentioned having seen^ a few years since, in consulta- 
tion with Dr. Coale, a young married woman, whose skin was covered with an 
eruption precisely like that of the patient who was before the Society ; she 
stated, that to her knowledge, she had never been troubled with chancres, or 
any other venereal symptoms, and her statement was made with apparently 
the greatest sincerity. Dr. D. has often heard similar declarations, especially 
from females whom he has attended for psoriasis syphilitica; he was quite 
aware that it is contrary to all medical authorities to suppose that the second- 
ary syphilitic developments can be manifested without having been preceded 
by the primary disease, and he would ask if a female might not have a chancre 
and yet not be conscious of any trouble in the part thus affected ? or, can it 
be possible for any of the secondary affections of the venereal disease to exist 
independently of chancre as the cause? 

Dr. Parkman referred to Ricord's statements as positive against the latter 
supposition, and suggested that the patients referred to by Dr. Durkee, may 
have been sufferers from the disease without having noticed its symptoms. 

Dr. Abbot mentioned the case of a woman who had applied to him for the 
treatment of an eruption which she supposed to be syphilitic, but she had 
never remarked any primary symptoms. 

lull/ 14. — Paracentesis Thoracis.— Dr. BowDlTCH reported the following 
cases of paracentesis thoracis, performed by means of the exploring trocar and 
suction apparatus, described by him at a previous meeting, and first used in 
this country by Dr. Morrill Wyman of Cambridge. 

The first was that of a man accustomed to hard labour in a machine shop, 
being required to raise a heavy lever, the end of which he rested upon his left 

* This paper, intended for publication in October last, was omitted by mistake. This 
accounts for its date being out of the proper order. 



104 Morland, Extracts from Soc. for Med. Improvement. [Jan. 



breast. Three months ago, he noticed a soreness of this part, which had' 
gradually augmented, attended with dyspnoea and debility, till he entered the 
Massachusetts Greneral Hospital. At that period, his accesses of dyspnoea, at 
night, particularly, were urgent; and all the time he had laboured breathing. 
The physical signs of extensive effusion into the left pleura were quite evident, 
with flatness over front and back, except at apex; change of position caused 
a slight but perceptible change of sounds; respiratory murmur almost null; 
gegophony ; prominence of the left chest, and dislocation of the heart to the 
right side of the sternum. July 15th, Oj of a bloody fluid was removed, 
with scarcely any pain, and with a great sense of relief to the soreness and 
distension of the chest, and the heart fell about two inches towards its usual 
position. The next day, patient felt better than at any time since his entrance, 
and he did not have again, while in the hospital, any severe accesses of dys- 
pnoea. He was punctured subsequently twice, and, finally, an external open- 
ing was formed by suppuration through the skin. Patient was growing 
weaker and left the hospital. The case was an interesting one to Dr. B., first, 
because of the unusual character of the fluid evacuated, it being so nearly 
like blood in its aspect, that he had, at first, desisted from drawing it off, 
fearing that possibly some organ had been punctured, although the physical 
signs were wholly opposed to that idea; secondly , because of the great relief 
to the dyspnoea and to the abnormal position of the heart. One of the punc- 
tures caused some pain ; the others occasioned but little. 

Dr. B. reported a second case, which was that of a little girl, about six 
years of age, the history of whose symptoms could not be exactly ascertained. 
She was under the care of Dr. Buckingham at the almshouse, and was evi- 
dently approaching her end, when first seen. The usual signs of great effu- 
sion were found in the left thorax. Three distinct punctures were made, in 
about as many minutes, with the small trocar, and, on each occasion, a small 
drop of watery fluid escaped, but by no power of suction could any large 
amount of it be procured. The patient suffered scarcely at all, and subse- 
quently to the operation, she seemed to the attendants rather easier than be- 
fore. She died, as was anticipated, the next day. 

A third case was given as follows: A. M., spinster, ast. 25, a thin, pale 
woman, had been troubled slightly with cough for a year or more, but was 
never long confined to bed by it. Two weeks before she was seen by Dr. B., 
she had had severe pain in the left side of the thorax, with sense of distension of 
that side, and inability to lie on the right side. Meanwhile, for a week, her 
cough had almost wholly left her. Her appetite was gone, and she had a 
slight diarrhoea, and some hectic paroxysms. Her pulse was 104; and the 
heart was pushed to the right of the sternum. There was flatness of the 
whole of the left chest; the respiration was very obscure in the lower half of 
the left back, strongly tubular in upper half; there was crackling, of a coarse, 
moist kind, at the top of the right lung. The diagnosis was chronic phthisis 



1852.] Morland; Extracts from Soc. for Med. Improvement. 105 

with serious lesion of the left lung, combined with acute pleuritic effusion of 
two weeks' duration. 

As the patient was too feeble to sit up, even for a short interval, she was 
raised by an assistant and the trocar introduced just below the angle of the 
scapula, between the eighth and ninth rib. Forty-one ounces of a clear, yellow, 
serous-like fluid were drawn off with instantaneous comfort to the patient. The 
left breast became somewhat resonant, and the heart fell back towards its 
normal position, at least one and a-half inches. The pulse was at 100 before 
and after the operation. A cough commenced during the operation, and be- 
came quite troublesome. 

The report, the next day, was that she had passed a delicious night, wholly 
free from pain and sense of fullness. From that period, the patient rapidly 
mended. The pulse fell, within twenty-four hours, to 80; the appetite re- 
turned; the dejections were regular. The respiratory murmur was heard, 
within the same time, much more distinctly, at the bottom of the chest. A 
fine crepitation, as from the expanding of previously compressed lung, was 
heard in the left breast, and the upper part of the back was duller than the 
lower. The symptoms steadily improved, and on the seventh day, the patient 
sat up three hours, and all signs of effusion had wholly disappeared. This im- 
provement has been progressive- The crackling, coarse and distinct, at the 
apex of the right lung, has diminished, and the tubular respiration at the left 
summit, though still very marked, is, perhaps, less extensive. In other words, 
the physical signs of phthisis have lessened, and the patient has been to visit 
her relations in a neighbouring State. 

Dr. B. regarded this case as a deeply interesting one, from the entire success 
resulting from the puncture in relieving the acute effusion, whereas if no punc- 
ture had been made, the patient, who had been gradually growing more sick, 
would probably have died. The fact, too, that the physical signs of phthisis 
have been somewhat lessened by the operation, is quite important. It proves, 
as far as one case can prove it, that the coexistence of phthisis with pleurisy, 
so far from militating against the operation, makes it more necessary for the 
welfare of the patient that paracentesis should be performed. 

July 14. — Peculiarity in a Case of Vaccination. — Dr. Hayward, Jr., 
reported the case of an infant, from three to four weeks old, in whom, on the 
fourth day after vaccination, the appearances were favourable; on the tenth 
day, however, there was no indication that the disease had taken ; the child 
was re-vaccinated without effect, but, on the second day after the second vac- 
cination, the first began to take effect and went through its proper course. 
The scab came off on the twenty-third day. 

July 14. — Variola after Vaccination and Varioloid. — Dr. Clark referred 
to the case of a lady who was reported to have died of confluent variola, 
after having been previously vaccinated, and after having also passed through 



106 Morland, Extracts from Soc. for Med. Improvement. [Jan. 

at least one attack of varioloid;" and expressed his doubts, supposing tlie 
other facts to be as stated, as to her ever having been well vaccinated. 

It seemed to him also veri/ unusual that variola should follow rather than 
precede varioloid. 

He is of opinion that vaccination, at any period of life, if repeated, at in- 
tervals of not less than twenty-one days, until it ceases to produce any local effect, 
will protect the individual, forever after, not only against variola, but against 
varioloid even in its mildest forms. 

The number of operations required for this purpose will not usually exceed 
two. 

Dr. CoALE had known several cases of secondary small-pox ; in every case 
the disease was severe. In two of these patients the pitting was very marked 
from the second attack. 

Dr. MiNOT mentioned the case of a girl who had been vaccinated, who af- 
terwards had variola under Dr. GtRAy's care, and finally died from an attack 
of varioloid. 

July 27. — Fracture or Dislocation of the Coccyx during Labour. Dr. 
CoALE. — In the second labour of a married woman, aet. 23, who had been 
confined four years previously, the process was hindered by the curving up of 
the OS coccyx. After waiting without any advance for three hours, the for- 
ceps were used. Ten days afterwards the patient was unable to leave her 
bed, and complained of severe pain at the end of the sacrum. On examina- 
tion, the end of the coccyx was found very movable, with crepitus. 

Dr. BiGELOW, Senior, had seen some cases of an affection of this bone, 
accompanied by pain, etc., especially in riding, where it could not be attribu- 
table to violence. 

August 25. — Ascites. — Dr. Storer mentioned a case of ascites occurring 
suddenly and increasing with great rapidity, now under his care at the Massa- 
chusetts G-eneral Hospital. The patient, a female, twenty-seven years of age, 
who had been previously perfectly well, left London, nine weeks since, for this 
country. A few days after going on board ship, she suffered from severe 
pain, affecting the whole of the right side, which was increased by the slightest 
effort, and was accompanied by cough. The pain continued for five days only, 
the cough was not removed for several weeks. Two or three days after the 
cessation of the pain, the patient discovered, for the first time, a distension of 
her abdomen; this gradually increased for three weeks, then became stationary, 
and has thus continued ever since. At the present time, her whole abdomen 
is exceedingly distended, rendering the walls very tense, and pushing the dia- 
phragm high into the chest. Across the umbilicus she measures forty-four and 
a-half inches; across the epigastrium, thirty-five inches. With the swelling of 
the abdomen, her lower extremities became anasarcous throughout. Upon 
examination of the chest, there is dulness of percussion over both backs, 



1852.] Morland, Extracts from Soc. for Med. Improvement. 107 



especially the right, where there is absence of respiration, resonance of voice, 
and segophonj. No appreciable derangement of the heart, liver, or kidneys. 
The patient states that she has menstruated but once during the last three 
years; and that was about six months since. For the last two years previous 
to her leaving England, she was employed in a lead factory, and although she 
never suffered from any of the affections usually produced by the absorption 
of lead, the blue line, characteristic of its presence, is perfectly apparent upon 
her gums. 

Oct. 27. — From the time of patient's admission until September 21st, she 
was bandaged and active cathartics and diuretics were administered ; at this 
period, although she was gradually diminishing in size, she was growing more 
feeble ; all active measures were stopped and a generous diet prescribed. She 
now measures thirty-four inches across abdomen, on a level with the umbili- 
cus, and thirty-six inches across the epigastrium ; having gained ten inches in 
the largest circumference. 

She has house diet,'' and is very comfortable. The catamenia have not 
yet returned. 

Dr. S. asked whether this ascites might not depend on some affection of the 
liver, not discovered ? 

Dr. Channing referred to certain cases reported by Dr. Chapman, where 
abdominal swelling and oedema of the limbs occurred in healthy persons, from 
merely falling, by sudden accident, into water. Dr. C. thinks he remembers, 
also, similar cases, reported by English writers : the hardships, privation, and 
exposure to which immigrants are liable, might have like effects. 

August 25. — Resolution of Tubercle under the use of Cod-Liver Oil. — Dr. 
C. E. Ware reported the following case: — August 29th, 1850, he was called 
to see the patient for the first time. She was a woman thirty-four years of 
age. Two years previously she had had slight hjBmoptysis. Through the 
spring and summer she had been losing strength and flesh. In June she was 
again attacked with haemoptysis, small in quantity, and from that time her 
expectoration had been tinged, more or less, with blood, almost every day. 
She had also been much annoyed by dryness of the mouth and fauces. Her 
menses had been perfectly regular. Her bowels had been somewhat loose, 
four or five dejections a day. At this time, the cough was moderate. The 
expectoration not very copious, viscid, semitransparent, generally brownish 
mucus, which she said was red when first raised. She complained of pain in 
the upper part of the chest in front, in her left side, and in her legs. She 
was up, and about, but fatigued by slight exertion. Pulse 116, regular. She 
presented no physical signs of tubercles. The respiratory sound was rather 
faint over both backs, but equal, vesicular, and without rales. The resonance 
on percussion was normal. 

In her family there was no tubercular tendency. She was of a nervous 
temperament, and of a tall and slender person. 



108 Morland, Extracts from Soc. for Med. Improvement. [Jan. 

Septemlber 3d, she commenced taking cod-liver oil. There was some in- 
tolerance at first ] but persevering with smaller doses for awhile, she was soon 
able to retain, without difficulty or discomfort, half an ounce three times 
a day. This was her limit; and at this dose, she continued without variation. 
Most of the time she took it in tincture of bark. She took various cough 
mixtures at difi'erent times; but depended principally upon McMunn's elixir of 
opium to secure exemption from cough during the night. 

She continued without any marked change in her symptoms, excepting 
that she was regularly losing strength and flesh, till December 13th, when Dr. 
"W. discovered deficiency of respiratory sound under both clavicles, and a bron- 
chial expiration under the right. There was no marked difference on percus- 
sion under the two clavicles. She had been able to keep up, and occasionally 
to walk out in the yard, till this time, when she lost all inclination to move, 
and by the last of December was confined entirely to her bed. Her exhaus- 
tion and dyspnoea were extreme, so as to render the answer of necessary 
questions very fatiguing to her. Her emaciation was great. Appetite 
gone. The catamenia were regular up to the middle of January 1851, when 
she had them for the last time. About the last of January there began to 
be some mitigation of her symptoms. Through February and March, an 
improvement was very obvious. By the middle of April, her pulse had come 
down to 96. The bowels were perfectly regular; strength and appetite 
were greatly improved; the cough was very slight; she talked easily, without 
apparent dyspnoea. But through the two previous months, while she had 
been constantly and regularly improving in her general health, a depression 
of spirits, and distrust of the reality of her amendment had been gradually 
affecting her. Previous to this, while as constantly losing as she was 
now gaining, she had been very cheerful, and resigned to what appeared 
to be her inevitable fate. She complained now of uncomfortable sensa- 
tions in the head, affecting her whole body and making her feel as if she 
should lose her reason. Although she had so far recovered her strength that 
she was able to go about the house, sit up all day, and even walk out in the 
yard, yet she was disinclined to move. Through April and May she did not 
gain so much in strength as she had done in February and March. By June, 
however, she was able to walk out, and take quite long rides. She had little 
if any cough, and a good appetite. Her pulse was at its natural standard. 
She occasionally expectorated a thin transparent mucus, now and then with a 
speck of blood in it. She spoke with perfect ease, in her natural tone. Under 
her clavicles the resonance on percussion was perfectly good, and the respi- 
ratory sound natural. She had taken her oil regularly up to this time, with 
the exception of a few days, at long intervals, when it would become loath- 
some to her, and she would omit it. 

Her dejection, however, was increasing. She began to be wilful, and irri- 
table in her temper — was unwilling to eat, and to leave her bed. About 
the first of July she began to retain her water. It was healthy when passed, 



1852.] Morland, Extracts from Soc. for Med. Improvement. 109 

and there was no irritation, tenderness, or indication of trouble about the 
bladder or its appendages. It became necessary to draw it oflf, to which she 
submitted with great reluctance at first, and finally absolutely refused. She 
at length became so unmanageable that it was thought advisable to send her 
to an insane asylum, to which place she was removed July 26th. At this 
time, there was no indication of other trouble about the bladder than reten- 
tion. She was able, without inconvenience, to go to the court house, and 
afterwards to ride out of town. 

She returned to her home July 30th, prostrated to the last degree, with all 
the symptoms of acute inflammation of the bladder. Scanty urine, bloody 
and purulent; exquisite pain, and tenderness about the neighbourhood of the 
bladder; pulse so feeble and frequent as to be uncountable; a cool damp skin. 
She died August 3d, 1851. 

At the autopsy, there was found universal adhesion of the right lung, old 
and firm ; adhesion of the upper half of the upper lobe of the left lung. In 
the upper and middle lobes of the right lung there were numerous cretaceous 
masses, some of them quite large, with the substance of the lung contracted 
and hard about them. No crude tubercles, or cavities. In the upper lobe 
of the left lung, there were similar cretaceous masses. Excepting for these 
appearances, the lungs were perfectly healthy. 

The bladder was found greatly contracted, and thickened in its parietes. 
The mucous membrane was in all parts intensely red, thickened, and coated 
with tenacious mucus and lymph. There was no peritonitis. All the other 
organs examined were healthy. 

This case is interesting from the patient's dying of another disease, and 
enabling the fact of her having had tubercular disease to be established 
by a post-mortem examination. The circumstance of her taking cod-liver 
oil may be a mere coincidence. There can be no doubt that patients do 
occasionally recover from unequivocal tubercular disease under other treat- 
ment. But it is an extremely rare thing for a person reduced by tuber- 
cular disease to the condition in which this person was, to so far recover. 
Dr. W. has never met with an instance where there was not a doubt as 
to the character of the disease. This would have been an unsatisfactory 
case had the patient survived. The more gross physical signs, such as those 
which indicate a cavity, were never present. Although from the extent of one 
of the cretaceous masses in the upper lobe of the right lung, and the con- 
tracted appearance of the lung in immediate contact, it is very probable that 
there had been a cavity there. Supposing that the oil had any influence in 
this woman's convalescence, it is an interesting fact, and of much practical 
importance, that she perseveringly continued the use of it for four months, all 
the time failing, before she began to experience any benefit. It may be that 
in cases where it fails of efiicacy, it has been too early abandoned. 

Three other young women, who were under treatment at the same time, 
whose history and symptoms hardly leave a doubt as to the existence of tuber- 



110 Morland, Extracts from Soc. for Med. Improvement. [Jan. 

cles, who have taken the oil nearly as long and in the same manner, have pre- 
sented almost as striking improvement, although they have at no time ap- 
peared so far reduced as this patient was. In other cases it has appeared to 
have little efficacy beyond a temporary mitigation of certain symptoms. 

Septemher 8. — Fracture of the necJcofthe Thigh- Bone^witlim the Capsular 
Ligament. — Dr. Parkman exhibited the specimen, from an insane woman, 
aged sixty-four, who died nine weeks after the accident. The points of in- 
terest were certain bands of lymph proceeding from the internal surface of 
the capsule to the broken surface of the upper portion or head of the bone, 
which Dr. P. considered might explain the means by which the part in these 
cases may acquire, as it often does, a degree of firmness and consequent use- 
fulness, although no hony union takes place. 

September 8. — Effect of Atmosplnric Electricity upon a Rheumatic Cripple. 
— Dr. Hayward, J r. related the following, which was told to him by a reliable 
individual who was present at the occurrence. A person at Sharon Springs, 
a cripple from rheumatism, recovered the use of his limbs, and rose from his 
bed, walking with ease, during a period of three hours after the house in which 
he lodged had been struck by lightning; a strong sulphurous odour was occa- 
sioned by the evolved electricity. 

The helplessness of the limbs returned, however, as before. 

Septemher 22. — Prolonged Secretion of Milk. — Dr. Kneeland reported 
the following case : — A lady, setat. thirty-five, had her first and only child five 
years since ; her husband died when this child was three weeks old, and she 
has not been again married. She nursed her child for two years, during 
which period, the flow of milk was so profuse that if she were absent two or 
three hours from her child, her dress would be completely wet; to use her 
own expression, " the milk would run down into her shoes.^' Her child died 
at the age of two years, of chronic hydrocephalus; since then, up to the pre- 
sent time, a period of three years, there has been a constant secretion of milk 
in her breasts, and so free as often to wet her dress quite through; during the 
last week she was able to express, by gentle pressure, a perfect stream of milk. 
She has been, and still is, regular in her menstrual periods, and also enjoys 
perfect health. 

Dr. Kneeland remarked that it is well known that, as a general rule, the 
secretion of milk is confined to females (human and animal), who have young 
to be suckled; also, that this secretion occurs in virgins, and, occasionally, 
even in males ; but these latter cases are rare and not easily explained, in the 
present state of physiology. The above case reminds us of the phenomenon 
of the lacteal secretion in our domestic animals, in whom it is perpetual : 
thus, the milking of cows is continued through the whole period from the 
time of their bearing young to that of cessation from breeding; this secretion 



1852.] 



Morlandj Extracts from Soc. for Med. Improvement. 



Ill 



in loild cattle, as in animals generally, and in the human female, is continued 
only during the suckling of the young. There is this difference, however^ 
that in the domestic animals, repeated impregnation is necessary to secure a 
continuance of the secretion, while in the case above given, there was only 
one impregnation, and that five years ago. 

Dr. K. added that what we see produced in the domestic animals, viz : a 
temporary function of the animal economy rendered permanent by an arti- 
ficial habit for many generations, we have, in the above case (and very likely 
such are not uncommon), produced suddenly and without any apparent cause. 
Whether it depend on the habit of lactation, for two years, having so modi- 
fied the lactiferous vessels that their secretion is permanently changed, whe- 
ther it arise from merely nervous causes, or be caused by any uterine sympa- 
thy (of which there is no evidence), it is difficult to say. 

The patient is not of a nervous disposition; she is very remarkably fond of 
children, almost to extravagance; this may be one of many elements to be 
considered in the explanation of the case. 

Recent microscopical researches have shown that in all forms of true secre- 
tion, the active agents are cells, which have the power of selecting from the 
blood the requisite materials ; these cells, developed in the interior of the 
organ, become distended, burst or liquefy, and yield their contents to the ex- 
cretory ducts. In the mammary gland, according to Mr. Goodsir, as in other 
glandular structures, the inner surface of the ultimate milk-follicles is covered 
by a layer of epithelium cells, the real agents in the secreting process; as 
fast as one set of cells discharge their contents and die, there is a new produc- 
tion of secondary cells, from the germinal spots or nuclei at the extremity of 
the follicles. The principal characteristic constituent of milk is casein, a 
highly 7iitrogenized principle, like albumen, of which it is a slightly altered 
form, and Dr. Grolding Bird has recently obtained evidence that this alteration 
commences in the blood, and goes on during pregnancy, as a preparation for 
lactation : the evidence is the presence of kyesteine (which is nearly related 
to caseine) in the urine during pregnancy, indicating the conversion of albu- 
men into casein in the blood, and preventing its accumulation in this fluid, 
before it is secreted by the mammae, by this curious substance in the urine. 
If these results are true, it does not seem so very strange that the secretion 
of the milk cells should be permanent, under favourable circumstances, which 
cannot, at present, be specified, any more than that the secretion of urine or 
of bile, once commenced, should be permanent. The secretion of milk, ab- 
normally continuous in the above case, may be only a transfer of the office of 
freeing the system from nitrogen, by the usual source, the kidneys, to the un- 
usual one, the mammse, which remove it by casein instead of by iirea, from 
idiosyncrasy, the former being permanently formed in the blood of this 
person. 

The following remarks, relative to the above subject, occurred after its re- 
port : — 



112 Morland, Extracts from Soc. for lied. Improvement. [Jan. 

Dr. Channing mentioned two cases of prolonged lactation; in the first 
the milk continued to be secreted for eight years; in the second, for four 
years ; he remarked that the spayed cow will secrete milk, continuously for 
several years. The cow, at length, grows very fat, and the milk ceases. 

Dr. Abbott asked if the urine of the above patient were diminished in 
quantity ? 

Dr. Kneeland was not aware of any diminution. 

Dr. CoALE deemed an analysis of the urine, in such a case, desirable and 
important. 

Dr. Stoker asked if hydrocephalus is not often a concomitant of these cases ? 
In Dr. Kneeland' s case, the child died of it. 

Dr. Channing said it did not exist in the two instances reported by him. 
He alluded to the belief (whether professional or merely popular he was un- 
certain) in England, that certain cerebral troubles arise from prolonged lacta- 
tion. 

Dr. CoALE mentioned an instance of a child being nursed for three years; 
this occurred in his own practice; the child was healthy; he knew of another 
case where a child of five years was in the habit of nursing. 

[Dr. Channing has since stated to the Secretary that one of the cases 
given, as above, by him (that of lactation being continued for eight years) was 
also mentioned at the last annual meeting of the Medical Society of Khode 
Island, at which he was present, with his friend. Dr. A. L.^Peirson, of Salem. 
It was stated during a discussion which arose after the delivery of the annual 
discourse, the subject of which was the re-estahlishnent of lactation after its 
cessation for weeks and even months, in consequence of febrile and inflamma- 
tory diseases of the puerperal state; such as puerperal peritonitis, nursing sore 
mouth, phlegmasia alba dolens, &c. The discourse was exceedingly interest- 
ing, and the discussion which followed presented many important facts.] 

September 22. — Paracentesis Thoracis in a case of Acute Pleurisy. — Re- 
ported by Dr. Williams. — The patient, a married woman, set. thirty-one, 
called on Dr. W. on 27th August, complaining of some difficulty in breathing, 
cough, and pains in right side. Her appetite was good, the tongue nearly 
clean, and the dyspnoea not greater than might accompany her situation, she 
being six months advanced in pregnancy. Ordered rest, demulcent drinks^ 
and sinapism to right side. On the 3d of September Dr. W. was sent for to 
see her, and found much dyspnoea, inability to lie on left side, and pain on 
making a full inspiration. Pulse 108 ; cough troublesome. Patient had 
been unable to sleep the previous night, and could not assume the horizontal 
position on account of the increased dyspnoea which results. 

Puerile respiration in left lung. Dulness on percussion, with absence of 
respiration and aegophony on right side, as high as an inch above the nipple. 
The level of dulness changes with position of patient. In consultation with 
Dr. Bowditch, the operation of paracentesis was decided on, and, the chest 



1852.] Morland, Extracts from JSoc. for Med. Irtiprovement. 113 



having been punctured by an exploring trocar, about an inch below the angle 
of the scapula, twelve ounces of serum were drawn out through the canula, by 
means of a stomach-pump. Not a particle of air was admitted, and it was 
not necessary to cover the slight punctured wound with any protecting plaster. 
The dyspnoea was relieved, and the pulse increased in strength immediately 
after the operation. Instead of being threatened with suffocation if she took 
the recumbent position, she was able to lie even upon the left side and enjoy 
refreshing sleep. 

A blister was ordered to be applied to the affected side. All the symptoms 
improved from the moment of the operation. A second effusion took place, 
but not sufficient to cause dyspnoea, and under the use of the iodide of potas- 
sium, with counter-irritation to the side, she rapidly recovered ; and, on the 
20th September, seventeen days after the evacuation of serum from the pleural 
cavity, she was able to sit up all day, and attend to most of her household 
duties. 

September 22. — Sequence or partial concomitance of Typlioid and Scarlet 
Fever symptoms. — Dr. Cabot related the case of a young man of sixteen 
years, who had been ill for four days with the usual symptoms (or certain of 
them) of typhoid fever j there had been epistaxis before Dr. C. saw the pa- 
tient, and it recurred several times afterwards. On the sixth day after the 
attack, the patient became covered with the eruption of scarlatina; there was 
great debility; after the eruption disappeared, the typhoid symptoms con- 
tinued; rose-spots were observed as the scarlet eruption left : there was des- 
quamation of the cuticle, as in scarlatina. During convalescence, the patient 
committed an imprudence by eating largely of meat, cabbage, etc. ; a relapse 
occurred, from which he is now recovering. 

To questions from Drs. Bigelow and Bethune, as to the presence of delirium 
or meteorism, in the above case, Dr. C. replied that there was slight mental 
disturbance. 

Dr. Bigelow alluded to the following of one disease upon another, as scar- 
latina upon measles, and vice versa ; they are never, properly speaking, coex- 
istent. Erysipelas he had known to follow scarlatina in one or two instances. 

The sequels of scarlatina, it is well known, may simulate distinct diseases. 
Dr. B. remarked the occurrence of shin affections in close conjunction with 
scarlatina. He particularly mentioned an eruption resembling roseola. 

October 13. — Ichthyosis Cornea. — Dr. DuRKEE related a case of this rare 
cutaneous affection. The patient is a merchant, thirty-two years of age, and 
in perfect health. The malformation is congenital and inherited from the 
father. The right side of the trunk and the corresponding limbs are impli- 
cated. The. integument of the face, neck, palm of the hand, and sole of the 
foot, is not involved ; nor has the disease (if it may be so termed), ever ap- 
peared, in the least degree, upon the left portion of the body or its correspond- 



114 Morland, Extracts from Soc. for Med. Improvement. [Jan, 

ing members. The morbid growth is most abundant and perfect in the axilla. 
Here it shows itself in the form of numerous well-defined spines, each about 
the size of a kernel of wheat; of a dark-brown colour^ and lying flatwise upon 
the skin. When the arm is raised upward and outward, the spines or prickles 
project out at nearly a right angle with the subjacent skin; they are very ad- 
herent, and cannot be torn from their attachment without producing consider- 
able pain. These prolongations have been compared by some dermatologists 
to the short quills of the porcupine; and persons troubled with them have 
been cdMed j^orciqnne men. Around the elbow joint is a broad patch of simi- 
lar growth to that just mentioned, although the spines are shorter than those 
in the axillary space, on account of the constant friction to which they are 
exposed. The same is true in regard to various other spots. The appear- 
ance of some of the patches is intermediate between ichthyosis simplex and 
ichthyosis cornea. The dorsal surface of the thumb and fingers, with the ex- 
ception of the middle one, is thickly covered with the excrescence, and the 
patient is obliged to cut it off as well as he can every five or six days with a 
pair of scissors. The spaces between the fingers are also the seat of this sin- 
gular annoyance. Some portions of integument upon which the abnormal 
development exists, are much more affected than others. There are large 
patches which consist merely in a slight thickening and induration of cuticle 
of a gray colour, and dotted over with small warty deposits, which are very 
hard and dry, and elevated slightly above the surrounding integument. 

The right side of the penis, including the glans and the cuticular and mu- 
cous surfaces of the prepuce, is also covered with the abnormal product, so 
that the organ is almost as rough as a nutmeg grater, especially when in a 
state of erection, according to the patient's own account. The seasons of the 
year produce little or no change in the condition of the affected skin. It is 
always in an unperspirable state wherever the disease exists; but from the 
healthy portion of skin the patient thinks the amount of perspiration is above 
the usual standard, as if the law of compensation was called into action. 
Patient was married three years ago. For the last fifteen or eighteen months 
his wife has suffered exceedingly from vaginal inflammation, caused, without 
doubt, by the peculiar epidermic condition of the virile organ. The lady is 
confined to her chamber much of the time, and is wholly unconscious that 
her partner in life is, in any respect, different from other men. The parties 
have not indulged in sexual intercourse for about a year. 

Dr. D. regretted that instead of exhibiting the patient to the Society, he 
must show some plates which were a transcript of those of Alibert, and which 
gave but a very imperfect representation of the case. 

It is said that this variety of ichthyosis was never known to appear on the 
skin of the female. It is produced by hypertrophy of the papillas ; and the 
only method of cure must be to destroy the papillas. The patient is extremely 
anxious to have the integument of the penis freed permanently from its pre- 
ternatural covering, and is willing to submit to any experiments that hold out 



1852.] Morland, Extracts from Soc. for Med. Ir}%provement. 115 

the slightest promise of ultimate success. Dr. D. had made some unsuccessful 
attempts with different caustics upon small patches on the arm. He would 
make still further trials, and, if successful, would try afterwards upon the 
penis, and report the result to the Society. 

Dr. Cabot suggested the use of arsenic as a local application in this case. 
The arseniate of iron is often used, empirically, as a depilatory, and might be 
effectual for the destruction of the hypertrophied papillae. 

October 13. — Recurring Salivation. — Dr. Storer, while going round his 
wards at the hospital, perceiving a strong mercurial odour, inquired who was 
salivated; he found that an Irish woman, just entered, and never previously 
seen by him, was thus affected; she came into the hospital with phthisical 
symptoms. Two years previously she had been salivated by a quack, since 
which the affection returns upon her with every ailment, the teeth becoming 
loose, &c. 

Dr. Strong mentioned a similar case ; the interval from the administra- 
tion of the medicine having been a longer one. 

October 13. — Urine containing Oil in large quantity. — Dr. BoWDlTCH 
showed the urine of a patient at the Marine Hospital, Chelsea; its colour was 
that of a mixture of molasses and water; oily particles were seen floating in 
it. The patient had been suffering for months with an obscure abdominal 
disorder, although the diagnosis was never satisfactorily made out, owing, 
perhaps, in part, to the great dullness of intellect of the patient. This 
existed in so marked a degree that the attending physician found it impos- 
sible to get any definite answers from him. One symptom of a curious 
nature was noticed — the urine so nearly resembled, in colour and quality, mo- 
lasses and water, that it was supposed the patient had mixed molasses with 
the excretion. This colour, however, was noticed daily, until death. Oil- 
globules of considerable size were likewise found on the surface of the liquid 
after it had been standing. On post-mortem examination, carcinoma of the 
liver and of a large portion of the pancreas was discovered; the kidneys 
were entirely healthy; urine taken from the bladder at the autopsy did not 
appear unnatural, but the microscope showed it to be full of oil-globules. 

Dr. Bowditch asked whether, as oil found in the feces is a sign of diseased 
pancreas, the same substance detected by the microscope in the urine may 
not become another means of recognizing this obscure disease ? Further ob- 
servations, he remarked, were, of course, necessary. 

Dr. Bowditch also reported the following case : — 

Troublesome Prurigo following Bronchitis in the Pregnant Female. — A se- 
vere bronchitis, partially relieved by syrups, &c., seemed far more relieved by 
2b pruriginous eruption, which, however, proved very annoying. Having tried 
many remedies himself, and those suggested by medical gentlemen more 
learned in skin diseases, and being still unable to relieve the distressing itching, 
No. XLY.— Jan., 1852. 9 



116 Morland^ Extracts from Soc. for Med. Improvement. [Jan. 

Dr. B. directed his patient to scvatch, ad libitum : This last remedy was almost 
entirely successful when used in conjunction with one that had been wholly 
inefficacious previously, viz : an alkaline wash. The patient scratched, when- 
ever itching occurred, until the cuticle was torn off in minute dots ; then the 
wash was applied, which caused much smarting, with entire cessation of the 
itching. This patient's mother suffered in the same way during the last 
month of some of her pregnancies, and could not obtain relief until after con- 
finement. 

October 13. — OJiolera Maligna. — Dr. Clark reported the following cases 
of cholera, as all which had come under his personal notice during the past 
season. 

August 18. — Case I. C. D., female, unm^arried, forty-nve years of age, 
had disturbance of bowels for some days; distinct symptoms of cholera for 
twenty-four hours before death. 

August 23. — Case II. M. B., shipping-master, forty-six years of age, 
married and temperate. After a very busy day, during which he drank large 
quantities of water and molasses, and after a hearty supper of corned-beef, he 
was attacked at 1 A. M. with cramps, a watery diarrhoea, and retching. The 
skin was blue, corrugated, cold, and wet, especially about the hands and feet. 
The urine was suppressed ; no pulse at wrist. A stimulant emetic was pre- 
scribed, to be followed by enemata of warm water and salt, and the patient 
allowed to drink freely of soda-water and of rice-water well salted; dry warmth 
to the whole body, and frictions to the limbs. 

The next morni-ng he was much relieved, and, in the course of two days, 
quite recovered. 

September 22. — Case III. Timothy Driscoll, thirty-eight years of age, 
labourer. Habits, uncertain ; married. Was attacked, without any previous 
ill-health, and died in forty-eight hours, with all the symptoms of cholera. 

September 24. — Case IY. Ellen Driscoll, thirty years of age, wife of 
above, same symptoms, and died night of 26th. 

September 25. — Case Y. Edward Hunt, thirty-one years of age, labourer. 
Not in previous good health, but at his work until date. Died on the 28th, 
with characteristic symptoms. 

The last three cases occurred in subjects belonging to the lowest class of 
life, surrounded by local conditions of the most favourable character for the 
development of disease of this nature; viz: crowded and badly-ventilated 
rooms, undrained and filthy yards and cellars. 

September 26. — Case YL J. T., Jr., twenty-five years of age, carpenter. 
Temperate. Fatal in fifty hours from the apparent commencement of the 
attack. He lived in a very healthy part of the town, but had been at work, 
for some days, in a cellar in the neighbourhood where the last case ori- 
ginated. 

October 11.— Case YII. Thomas Fiynn, twenty-four years of age, la- 



1852.] Morlandj Extracts from Soc. for Med. Improvement. Ill 



bourer. Temperate. Two days ago, was taken with violent cramps while at 
work in the hold of a steamship at India wharf, in the afternoon, after drink- 
ing excessively of small beer and iced-water. At 10 P. M. he had all the 
signs of cholera — viz: loss of pulse and voice; coldness and corrugation, 
and the leaden-coloured skin. Confesses to but two or three loose dejections 
during the day or evening. With Dr. Green's concurrence (whose patient he 
was), he was directed to have the saline mixture of Dr. Stevens, in such 
doses that he got about ten grains of the chlorate of potass every half hour 
until reaction should be established. In addition, the usual external applica- 
tions. 

At 8 A. M. he had partially recovered his pulse and warmth, and had also 
passed an ounce or two of urine, the first for eighteen hours. 

The chlorate was suspended until 3 P. M., when, the patient becoming 
again partially collapsed, it was resumed. 

At 8 A. M. of the second day he had rallied effectually, and the saline 
mixture was discontinued, and the patient ordered a light tonic mixture. 

At 3 P. M. a plentiful tt/plius eruption had appeared upon the body and 
limbs. Patient otherwise in a fair way of recovery, having a good pulse and 
free secretion of urine. 

Dr. Clark noticed particularly, in alluding to the above cases, the noxious 
influence of filth allowed to remain near dwellings, and especially animadverted 
upon the state in which disused vaults are left. 

Dr. CoALE also testified to the malarious influence of such vaults. He had 
seen, on Saturday last, one of these, where, by the pressure of the soil around 
it, a mass of filth is pushed up and exposed ; a store is extended over this 
vault, and the consequent nuisance is very great. Dr. C. had likewise known 
a valuable well spoiled by the same means. 

Dr. Clark referred to one existing near a furnace, built under a dwelling- 
house, which made itself rapidly evident on lighting a fire in the furnace. 

Dr. C. II Ware had seen one case of unequivocal cholera in August; the 
patient was from the south ; somewhat depressed by trouble in his business ; 
after a hearty dinner he was attacked by diarrhoea ; his illness became choleraic, 
and collapse, with suppression of urine, finally came on. He, however, rallied 
and recovered. 

October I'^lli. — Poisoning hy Laudanum — Tobacco as an Emetic. — Dr. 
Strong related the case of a female who took of laudanum with suicidal 
intent. When Dr. S. saw her, she was pretty thoroughly narcotized ; she had 
already taken grs. xx of ipecacuanha without effect ; the skin had assumed a 
very dark hue ; she was nearly insensible to all impressions. 

Dr. S. administered grs. Ix of sulphate of zinc, in three doses; patient's sense of 
taste was lost; no emesis occurring from the zinc, mustard was given with some 
efi"ect; she was now " walked about," which required great eflbrt on the part 



118 Morlandj Extracts from Soc. for Med. Improvement. [Jan_ 



of tlie assistants, tlie muscular system being so greatly relaxed. Finally, infu- 
sion of tobacco, in large quantities, was given to her in coffee; powerful emesis 
and gradual return of vitality resulted. 

Dr. S. bad never seen a case so far gone recover ; be attributes success to 
tbe unremitting action kept up upon tbe stomacb. 

Dr. H. Gr. Clark referred to tbe mode of evacuating tbe stomacb in sucb 
cases recommended by Dr. Epbraim Buck, of tbis city. A solution of some 
alkali is first introduced into tbe stomacb, and tbis is followed by vinegar j 
tbe effervescence is so powerful tbat all tbe contents of tbe viscus are dis- 
cbarged; and, if emetics bave been taken ineffectually, tbey begin to act. 

[Tbe Secretary remembers baving adopted tbis metbod very successfully, 
eigbt years since, in tbe case of a young cbild seized witb very violent 
and almost continuous convulsions, arising from tbe ingestion of very indigest- 
ible food in large quantity. Tbe usual emetics, in greatly increased doses, 
baving bad no effect, and it being impossible to excite vomiting by irritation 
of tbe fauces witb a featber, wbicb was tried ; and equally so to introduce tbe 
finger, witb a like intent, by reason of its liability to injury from tbe convul- 
sive closure of tbe teetb, &c. ; a solution of tbe carbonate of soda was tbrown 
into tbe stomacb (tbe teetb being kept apart by tbe introduction of a bit of 
wood) by means of tbe stomacb-pump, and tbis was followed directly by nearly 
as mucb vinegar ; tbe evacuation of tbe contents of tbe viscus was exceed- 
ingly speedy and very complete. No more convulsions were observed, nor any 
of tbe stupor previously noticed intervening between tbeir accesses.] 

Octoher l^th. — Stryclmine as a Cumulative Poison. — Dr. Storer related a 
case wberein be bad given strycbnine to a paraplegic bospital patient wbo bad 
been addicted to masturbation. Tbe medicine bad appeared to bim to act 
suddenly and strongly by force of cumulative power. It was first given on 
tbe 7tb of September last, six drops of a fluid preparation containing grs. vj 
to of alcobol. Tbe dose was increased very gradually, as follows : — 

September 7th. Gtt. vj. — 9t7i. Grtt. viij. — 11th. Gtt. x. 

12th. Medicine omitted ; pain in forebead. 

22c?. Medicine given in pills, gr. one-twenty-fourtb. — 2^th. Increase to gr. 
one-twentietb. — 27th. G-r. one-sixteentb. — 2Sth. Gr. one-twelftb. — October 
2d. Gr. one-tentb. — 4:th. Gr. one-eigbtb. — 7th. Gr. one-sixtb. — Sth. Gr. one- 
fourtb. — 12th. Gr. one-tbird. 

l^th. Very severe convulsions occurred, lasting for ten minutes. 

Ibth. Patient can move tbe toes of left foot, tbe one affected, wbicb bas not 
been done since bis entrance. 

Dr. Channing asked if one-tbird of a grain were not sufficient, of itself to 
act tbus powerfully, witbout referring to its supposed cumulative power ? 

Dr. Storer said tbat one-fourtb of a grain is often sufficient to cause equally 
marked effects, but it did not in tbe above case, and gr. ss is sometimes given. 



1852.] Morland; Extracts from Soc. for Med. Iviprovement. 119 



Dr. Strong had seen powerful convulsions follow the administration of one- 
sixtieth of a grain. 

Dr. C. E. Ware had given gr. one-twelfth, for some time, in a certain case ; 
one day, after the usual dose, a very strong eflfect was produced upon the system. 
Dr. Ware found that a new supply of the medicine had been obtained, and 
that the pills were unequally made up. He thought the effect produced in 
Dr. Storer's case more likely due to sudden, large increase, than to cumulative 
action. 

In reply to Dr. Ware, Dr. Storer, referring to the tabular account of the 
doses given, said he could not discover any " sudden, large increase" of the 
medicine. 

Dr. Clark related the case of a patient eighty years of age, who, for a 
hemiplegic attack, with threatening of apoplexy, was treated by tincture of 
nux vomica; dose ten to fifteen drops. By mistake, ^ss of the tincture was 
given; very violent convulsions followed, endangering life. Recovering from 
these, however, the patient's limbs began to get better immediately; he is now 
nearly ninety, and quite well. 

October 27th. — Membranous Croup, treated by the application of Nitrate 
of Silver to the Trachea. — Dr. J. B. Alley reported the case. — The patient 
was at first under the charge of Dr. Spooner, of Milton; subsequently, Dr. 
Holmes, of Milton, was called in, with whom Dr. Alley saw it in consulta- 
tion. The patient was a boy five years old ; always had been called a croupy 
child; mother's family much predisposed to croup; tonsils much enlarged. 
Child first seized on Saturday eve; sibilant rales heard in chest; false mem- 
brane first observed in the throat on Sunday evening. 

Dr. Alley saw the patient for the first time after the attack, at half-past ten 
on Monday morning. It was then lying in the nurse's arms, the head thrown 
back, nostrils much dilated, countenance anxious, breathing very laborious, 
accompanied with a crowing sound; pulse 140. With the consent of the at- 
tending physicians. Dr. A. applied a solution of nitrate of silver, to of 
water, by means of a sponge fastened on the end of a piece of whalebone, 
passed into the larynx and trachea. On the withdrawal of the sponge, there 
appeared, adhering to it, shreds of false membrane, and, a moment after, the 
child threw np a quantity of mucus and phlegm, in which could be distinctly 
seen the shreds of membrane. For two or three hours the child's breath- 
ing seemed to be much relieved, and it coughed loosely. In the course of four 
hours, the breathing becoming more laborious, and the crowing sound, which 
had in a measure disappeared, returned. Reapplied the nitrate of silver, with 
similar result, but yet the disease seemed to be beyond the reach of the applica- 
tion. At eight P. M., the child vomited what appeared to be false membrane. 
From eleven to one, the child had a severe paroxysm of dyspnoea, correspond- 
ing to a similar one on the preceding night; applied the solution, but with 
some difficulty, as the child was uneasy and restless. Towards morning, the 



120 Morlandj Extracts from JSoc. for Med. Ijivprovemenf. [Jan. 

child's strength began to fail, the breathing became more and more laborious, 
the countenance more anxious, and the features swollen and darkened; pulse 
frequent, and respiration sixty in a minute. Coldness of extremities. Stimu- 
lants were resorted to, but without much effect, and the little sufferer was 
relieved by death at a quarter past four P. M. Tuesday, sixty-six hours from the 
commencement of the disease. 

The early treatment of the case was homoeopathic. Sunday eve, Dr. Holmes 
was called in, and recommended the usual external applications, and the air 
of the room was moistened by the evolution of steam. Dover's powder was 
given. No means, however, were used which tended to greatly reduce the 
system, nor was the child one who could have borne active treatment. The 
application of the nitrate of silver was followed by decided relief of the 
dyspnoea, and the air entered more freely, for the venous circulation appeared 
less marked, and the cough became looser. The disease appeared to the phy- 
sicians to commence below, and then to ascend, because there were sibilant and 
sonorous rales in the chest, and the membrane appeared above, after the child 
had been seized with the first symptoms of croup. It seemed to Dr. A. that, if 
the membrane had not extended so deeply into the bronchia (as appeared at the 
po&t-mortem examination), the chance of saving the child^s life would have 
been much increased, and that in an ordinary case of membranous croup, com- 
mencing in the pharynx and going downwards, a great reliance may be placed 
upon the application of the nitrate of silver. Examination twenty hours 
after death. Child, three feet four inches in height, chest full, no emaciation. 
Making an incision, and lifting up the sternum, the lungs appeared in perfectly 
healthy state. Removed the trachea by an incision above the epiglottis, in- 
flated the lungs; every lobe filled out except the upper lobe of the left lung. 
Made an incision whole length of trachea to bifurcation, found shreds of false 
membrane along course of trachea, and the bronchial entrance to upper left 
lobe closed with false membrane. The track of the sponge was distinctly 
seen along the surface of the trachea, and the membrane had been dislodged 
in many places. Opening the oesophagus, no trace of the solution appeared 
upon the surface of its mucous membrane or upon the stomach. All the 
other organs were healthy. 

October 21 th. — Wound of the Abdomen^ fatal in twenty-two hours. — Dr. 
S. D. ToWNSEND related the post-mortem appearances observed in a man who 
died at the Massachusetts G-eneral Hospital from a stab given by a clasp-knife 
in the hands of a man with whom he was in company. 

A wound one inch and three-quarters long existed about two inches above 
anterior superior spinous process of left ilium; it extended backward towards 
the crista ilii, was a clean cut, and had been closed by three sutures before 
the patient was brought to the hospital. 

On opening the peritoneal cavity, offensive gas in considerable quantity 



1852.] Morland^ Extracts from Soc. for Med. Improvement. Vl\ 

escaped; the intestines floated in a dark reddisli-brown fluid, which contained 
feculent matter. Recent unorganized bands of lymph between the coils of 
intestines. Patches of lymph and adhesion of the peritoneal surfaces were 
observed. Small intestines considerably inflamed. 

Upon turning down the parietes of the abdomen, an internal wound was 
discovered, nearer to the median line of the body than the external, with 
which it communicated; its lower angle opposite to the upper angle of the 
outer wound. The internal wound was about two inches in length, and 
through it, a band of omentum, three inches long, was drawn, strangulated 
and highly inflamed. Considerable force was required to extricate this stran- 
gulated band from the wound. 

Extensive ecchymosis around the wound. About four feet from the pylorus, 
a clean cut into the jejunum was found, an inch in length, and opposite, near 
the mesentery, a second, half an inch long. 

The stomach somewhat inflamed, and partially filled by a thick, dark-coloured 
fluid, like that observed in the small intestines, and also similar to the matters 
vomited just before death. 

One pint and a half of fluid were contained in the cavity of the abdomen, 
made up, apparently, of blood, pus, and feces. 

Octoher 27. — Kousso as a Remedy for BothriocepJialus Latus. — Dr. Abbot 
mentioned the use of this article, successfully, in two instances, the larger part 
of the parasite being apparently brought away in each case; the head, how- 
ever, had not been seen. 

Dr. DuRKEE referred to four cases wherein kousso had been used ; two 
successful, two not so. 

Dr. Clark spoke of Mr. Teschemacher's account of success against the tape- 
worm by the use of pumpkin seeds. 

Dr. Jackson had known pumpkin-seeds very effectual in one instance. 

Octoher 27. — Hemorrhage from the Bowels in Typhoid Fever; its fre- 
quency, treatment, &c. — Dr. Storer asked what is the frequency of hemor- 
rhage from the bowels in typhoid fever? He could recall but three cases of 
any severity as having occurred in his practice. In two of these, the patients 
recovered, although in one of them the bleeding was profuse, and the patient 
was exceedingly reduced by it. 

Dr. S. had seen to-day a death from this cause. A man, aged about thirty, 
during convalescence from typhoid fever, had a relapse in the third week. 
This morning, the patient suddenly had two very large evacuations of blood, 
estimated at from three to four pints. Dr. S. was called, and found him much 
prostrated; cold, and almost pulseless. Stimulants and astringents were ad- 
ministered without effect, and, upon the recurrence of the hemorrhage, more 
profusely than before, he expired, about three hours after the first bleeding. 



122 Morland; Extracts from Soc. for Med. Improvement. [Jan. 

Dr. CoALE said lie could not speak as to the frequency of this accident ; 
he referred to a case occurring in his practice in April last, in a person con- 
valescent from typhoid fever; pure, liquid, venous blood was first passed, and 
then coagula came away; after being arrested, the flow returned and proved 
fatal in forty-four hours from the first attack. 

Dr. HoMANS, in 1822, had seventy-two cases of typhoid fever, among 
which were only two of bleeding from the bowels ; one of these latter was 
fatal; in 1840, out of thirty cases, there were three with this hemorrhage; 
none fatal. The blood was always coagulated; the first bleeding invariably 
the most profuse. Dr. H. never saw it recur more than three times in any 
one patient, and remembers but one fatal case. He does not now attempt to 
arrest the bleeding; astringents do more harm than good; he considers the 
hemorrhage an efi"ort of nature. 

Dr. BiGELOW, Sen., had always considered this bleeding a very grave symp- 
tom; if the hemorrhagic diathesis be very marked, there is rapid sinking. 
Dr. B. has seen hemorrhage from the nose, lungs, urethra, and bowels in the 
same patient within twenty-four hours. A dose of castor oil will often arrest 
the latter; moderate astringents and injection of cold water are sometimes 
required afterwards. 

The discharge is analogous to the diarrhoea of typhoid fever, and is to be 
controllecl, not suddenly checked. 

Dr. J. B. S. Jackson said his experience accorded with that of Dr. Bige- 
low. Even when the bleeding is quite profuse, it is rarely fatal ; marked relief 
is sometimes observed from it. On post-mortem examination of these cases, 
Dr. J. has not found Peyer's patches ulcerated; in one instance only does he 
remember such lesion; in that case, a coagulum was observed hanging off 
from the face of an ulcer near the caecum. The intestine is often found 
stained, and sometimes a congested state of the vessels is remarked, but no 
ecchymosis. 

Dr. J. testified to the strikingly good effect of castor oil in one of Dr. Bige- 
low's hospital patients. 

In answer to Dr. Bigelow, Dr. Storer asked if the appearance of the blood, 
and the greater or less prostration of the patient, would not make a difi"erence 
as to the administration of the oil ? and whether, although he might be dis- 
posed to give it, if coagula were passed, particularly if they had the appear- 
ance of having been formed for some time, he would pursue this course if 
licjuid blood should be found freely flowing, and the patient rapidly sinking ? 

Dr. Bigelow replied that, in cases of extreme prostration, the physician 
should pause and weigh the case well before acting ; even in such instances, 
he thought the removal of any ofi"ending matters would be well, perhaps 
combining an astringent with the oil, or following the latter by one. 

Dr. B. said that the blood, in many of these cases, may be furnished by 
exhalation, without positive lesion of the intestinal surface? Dr. Jackson 
said he had always supposed this to be the case. 



1852.] Mov\-M\(iy Extracts from Soc. for 3Ied. Improvement. 123 

Novemher lOfh. — Dr. BiGELOW, Sen., referring to the discussion, in regard 
to hemorrhage from the hoivcls in typhoid fever, which occurred at the last 
meeting, said he has now in the hospital a female patient who entered No- 
vember 1st, was attacked fourteen days previously, and has had most of the 
grave symptoms usually observed in typhoid fever. On the fourth day after 
her entrance, she lost Oss of blood from the bowels. 

Dr. B. ordered Jij of castor oil, a small dose only, she having some diar- 
rhoea ; two grains of the acetate of lead to be also taken after each subsequent 
sanguineous discharge. Next day, it was ascertained that there had been five 
discharges of blood, not, however, so large as the first ; and that the oil had 
not operated. B. Olei ricini ^vj, to be followed by sulphuric acid. A fecal 
discharge, containing some blood, was procured by the oil, and, subsequently, 
there were several fecal discharges ] the next day a natural discharge took 
place, and no hemorrhage afterwards. 

In this case, observed Dr. B., the acetate of lead did not arrest the bleeding; 
the oil, in operative dose, seemed effectual. The case is progressing, with de- 
lirium, quick pulse, restlessness, &c. ; and this day profuse monorrhagia has 
supervened. The blood passed from the bowels was not coagulable. The pass- 
age of defibrinated blood is an indication of greater gravity of the disease. 
He remarked that French writers report a mortality of wiore than half of 
these cases of intestinal hemorrhage in typhoid fever. 

Dr. Stoker said that it would be remembered that in Dr. Homans' cases 
there were, invariably, coagida. 

Dr. BiGELOW reiterated his opinion, given at the last meeting, in reference 
to the treatment of this accident, by operative doses of castor oil. In a con- 
siderable number of cases, he had found the hemorrhage to cease on the pass- 
age of the oil: Without such evacuation, large doses of astringents were often 
ineffectual. 

[GrRisoLLE notices intestinal hemorrhage in typhoid fever as a grave symp- 
tom; it nearly always increases the patient's feebleness, however small it 
may be ; is very frequent in the adult, quite rare in youth ; sometimes arising 
from erosion of a bloodvessel, it most often is passive, and occurs by exhala- 
tion ; occasionally, it is very profuse. This author advises the suspension of 
purgatives; iced lemonade; cold applications to the abdomen, and cool injec- 
tions; if the bleeding be persistent, astringents, especially rhatany by the 
mouth, and also thrown up the rectum. — Path. Intern, vol. i. pp. 42, 57.] 



124 Ballou, Reproduction of Lactation. [Jan, 



Art. yil. — On the Reproduction of Lactation. By Ariel Ballou, M. D. 
(Read before the Rhode Island Medical Society, June, 1851.) 

Some years since, from considering the physiological laws on which the ac- 
tion of the various glands of the human system perform their functions, and 
that few, if any of them, are in an active state without a given stimulus, and 
more particularly from contemplating the laws controlling the action of the 
glands connected with weeping, mastication, deglutition, and digestion, I was led 
to the inquiry whether the fact of the continuance of lactation depended upon 
some peculiar condition of the system growing out of, and dependent on preg- 
nancy and its attendant circumstances, or on the stimulus the child exerts upon 
the mammas in its efforts to obtain nutriment from them, connected perhaps 
with the mental desires of the mother to foster and nourish her offspring. • 

That pregnancy, parturition, and the attendant action of the uterus stimu- 
late the mammae into action, producing the secretion of milk at the commence- 
ment of lactation, there was in my mind little or no doubt. But that some 
peculiar state or condition of the uterus and of the system continued to exist 
during the period of lactation, essential to it, and upon which the secretion 
depended, seemed to be a conclusion not sustained by facts and observation, 
and at variance with the laws controlling the action of other glands and their 
secretions. 

Indeed, in numerous instances, all the functions of the uterus, common to 
unimpregnated women, were performed, and still lactation continued, in some 
instances during a period of two, and even more years. It appeared to me 
that these facts and considerations were sufficient to preclude the idea, if it 
existed in the mind of any one, that a certain condition of the uterine system 
were necessary to the existence and continuance of lactation. Hence I came 
to the conclusion that the stimulus arising from the application of the child to 
the breasts, and its efforts to obtain nutriment, aided perhaps by habit, were 
the true causes of the continuance of the secretion of milk. 

The foregoing train of reasoning, several years since induced me to test 
the truth of the matter, in order, should it prove to be correct, to avail my- 
self of its advantages in practice. Accordingly, in several cases where dis- 
ease had checked the secretion of milk, and a suspension of the function of 
lactation of necessity ensued; after recovery, in cases where there was no 
return of the secretion, I ordered the child to be applied to the breasts two, 
three, or more times daily, with a uniform result, a renewed secretion of milk. 

In other cases, when debility was present, growing out of disease or preg- 
nancy, or dependent upon the exercise of the function of lactation, and when 
the system was unable to sustain itself under so great a tax upon its powers, 
I have directed the removal of the child for a season, and the drying up of 
the milk, so to speak, until the recuperative powers of the system could pro- 



1852.] 



Ballou, Reproduction of Lactation. 



125 



duce vigour and more perfect health. After the restoration of healthy I have 
advised the rcapplication of the child to the breasts^ when it has in a few days 
uniforml}^ obtained the usual supply of nutriment. In no instance have my 
expectations been disappointed. 

I cannot exemplify my views and practice on this subject perhaps better 
than by giving the following cases : — 

Case I. — In the autumn of 1836, Mrs. J. G-., aged between thirty and 
forty years, of sanguine temperament, robust constitution, and the mother of 
several children, was confined. The presentation was natural, and no unusual 
circumstances attended her delivery. Subsequently she suffered from an 
attack of phlegmasia dolens in both of the lower extremities, attended with 
high febrile action, and, as is usual in such cases, extreme suffering. The 
secretion of milk ceasing early in the disease, the child was removed to a wet 
nurse, with whom it remained three or four months, during which time there 
was no return of milk. In the spring of 1837, the family being about to 
move a short distance from the village, where they could enjoy a better air 
and a more unrestricted exercise, the mother was anxious to take her infant 
with her, but did not like to deprive it of the advantages of the breast during 
the then coming warm season. I advised the mother to take her child and 
apply it to the breasts in the same manner she would do if she had a flow of 
milk ; assuring her it was my confident opinion that in two or three weeks she 
would have milk, and a sufficient quantity, at least her usual supply. 

She did so, and in about two weeks the secretion of milk was reproduced. 
She continued to nurse her child for more than a year, producing her accus- 
tomed quantity of milk. 

Case II. — Mrs. D., aged about twenty-five years, was confined in De- 
cember, 1841. Nothing worthy of note transpired during her confinement 
and recovery. In April following, her child weaned itself in consequence of 
a sore mouth. Her milk soon entirely disappeared. In July following, I 
was called to see her child, which was suffering from an attack of cholera in- 
fantum. Having lost several children about that time from this disease, 
I expressed my regret that the child was deprived of the benefits of the breast, 
adding that, in my opinion, its chances of recovery were diminished in con- 
sequence. 

The mother was informed of the course I had advised in other cases where 
it was desirable to reproduce the secretion, and of the results. On my visit 
the succeeding day, she informed me that she had applied the child to the 
breasts, and that it nursed and seemed pleased and more quiet ; but she was 
not aware that any milk was obtained, or that she had any for it. I advised 
her to persevere in the application of the child to the breasts, which she did, 
and the child recovered, and in the course of a week or ten days obtained a 
full supply of nutriment from the breasts. 

The mother continued to nurse for months with as full and perfect a secre- 
tion of milk as though no interruption in the secretion had occurred. * 

The following case I report as having an important practical bearing on the 
treatment and disposal of a class of cases, which occur in our community at 
the present day, to cure which, or otherwise dispose of satisfactorily to the 
physician, is often found difficult. 

Case III. — Mrs. 0. H. H., aged about twenty-one years, of feeble consti_ 
tution, and nervo-lymphatic temperament, was confined in July, 1847. Pre_ 



126 Parkmaii; Relations of the Medical Witness with the Law. [Jan. 



vious to her accoucliement, she was troubled with chronic aphtha, red canker, 
or with that condition of the system which is well known as "sore mouth 
attendant on pregnancy and lactation/' Nothing unusual occurred at the 
time of delivery. No considerable loss of blood was sustained. As in similar 
cases there was a remission of diarrhoea and sore mouth for a few days after 
accouchement, giving rise to a hope that, being relieved from the condition of 
pregnancy, she would recover the powers of digestion and the assimilation of 
nutriment, so as to enable the system to sustain the calls upon it consequent 
to lactation. But in the course of ten or twelve days after accouchement, the 
sore mouth and diarrhoea returned with increased violence, producing great 
debility. The secretion of milk was copious. Her pulse 120, the tongue 
flabby; there were frequent copious dejections of yellowish water, the face and 
extremities bloated, &c. Fearing the worst results for my patient, I advised 
the immediate removal of the child from the breasts of the mother to those of 
a wet nurse^ at the same time informing the parents that^ on the recovery of 
the mother, she could at pleasure reapply the child to the breasts, and have a 
full supply of milk, and be enabled to perform all the duties and functions of 
a mother for an indefinite period of time. The child was given in charge of 
a wet nurse, the milk gradually disappeared, and the patient recovered under 
the use of tonic remedies and a generous diet. Between two and three months 
after this, the mother called on me, having the appearance of restored health, 
and inquired if she might now take her child home with a hope of realizing 
my former assurances that she would be able to reproduce her milk. I as- 
sured her there was no doubt in relation to such a result, and her ability for 
the future to nurse her child. She took the child, applied it to the breasts, 
and in the course of two weeks had a good supply of milk. 

I met her some nine months after, when she informed me she was happy 
in the enjoyment of good health, and, to use her words, she "had as good 
a breast of milk as if she had never dried it up.'^ 

With these cases I close this paper. If, upon further and more extended 
trial, the results shall prove the same that I have described, we may hope a 
course of treatment will suggest itself to practitioners which will relieve 
them in many instances from embarrassment, and add new honours to the 
profession. 



Art. YIII. — On the Relations of the Medical Witness with the Law and the 
Lawyer. By Samuel Parkman, M. D., one of the Surgeons of the 
Massachusetts Greneral Hospital. (Bead to the Boston Society for Medical 
Observation.) 

The summons to appear as a witness in a court of justice is generally 
received by medical practitioners with feelings of disinclination to comply, 
prompted, not solely by the trouble and loss of time which an attendance of this 
kind involves, and which would apply with equal effect to all classes of society 
who are called upon in this way to render their quota of support to the 
Institutions of the Law, but with feelings peculiar to themselves as a class, 
dependent upon the supposition that they are about to be subjected to an ordeal 



1852.] Parkmaiij Relations of the Medical Witness with the Lavj. 127 

from which they can hardly expect to escape unscathed. The medical man 
alleges that^ on the stand, he is liable to be browbeaten by ingenious and 
unprincipled counsel — to have his opinions misrepresented by the demanding 
of a degree of accuracy which is impossible — or to be entrapped into state- 
ments seemingly contradictory by artfully devised questionings ; that, in fact, 
he is in various ways subjected to treatment which he has a right to consider 
unfair and illiberal. The lawyer is regarded by the medical practitioner as a 
species of grand inquisitor, who, although he may not have at his command 
the means of physical torture, by which evidence of old was extracted from 
an unwilling or incapable witness, has still the power to stretch the unlucky 
physician upon a kind of intellectual rack, which, having unhinged every 
joint, and fractured every bone of his mental frame, leaves the mangled car- 
case of his testimony as formless and misshapen as the trunk of Quasimodo 
released from the screws and pincers of the hangman of Paris. 

Such, it cannot be denied, is the general feeling with which a medical man 
approaches a court of justice; his only desire and hope is to escape from it 
without a blunder, or the appearance of one; and he considers any subterfuge 
lawful by which he is freed from such an annoyance. In a word, a doctor is 
apt to look upon a lawyer as his natural enemy, against whom his only defence 
is that of the hare against the hound, viz., flight. 

Now, it may not be without interest to examine a belief so prevalent and 
universal; to inquire if it be founded in reality, or whether it may not be the 
result of misconception and misapprehension. 

There are two conditions in which a medical man may find himself in a 
court of justice as a witness: 1st. To give his testimony as regards the facts 
of a medical or surgical case which has come under his knowledge ; and2dly. 
As an expert to give an opinion, either upon the testimony furnished by 
others to the court to enlighten their judgment, or to perform certain mani- 
pulations under the direction of the court, such as the making of an autopsy 
or a chemical analysis. 

As regards the first of these cases, it will be sufficient if it be shown that 
the physician is no greater sufferer than any other individual who may be 
cited to give testimony to facts which have come under his cognizance. It is 
not necessary to prove that there is no hardship in being subpoenaed as a wit- 
ness; it will only be requisite to show that the physician is no more liable than 
any other profession. We all yield a certain amount of liberty, that we may 
enjoy the advantages of society; we subject ourselves to law, that the lawless 
may be restrained. It is not pretended that perfect justice or perfect right 
is attained, or even attainable; all that can be done is to distribute the amount 
of inconvenience, and to permit immunity or privilege to no one. A court 
of law is the means of arriving at justice; it may be imperfect, but it is the 
best we can have. It is clear, however, that the ends of justice would be de- 
feated between man and man, and the citizen and the State, if all testimony 
were voluntary; if a witness might or might not present himself, as inclination 



128 Parkman^ Relations of the Medical Witness with the Law. [Jan. 

prompted him. To obtain this great end, therefore, the members of society 
have agreed that they will be bound always to appear in court, with any tes- 
timony they may have, to the exclusion of all other engagements or employ- 
ments. This duty shall be peremptory. Such is the law, and undoubtedly 
it is a just one; and, under this law, the physician, who has any knowledge 
of the facts relative to any individual case, is liable to be called upon for his 
testimony to those, as would any other member of society to the facts of any 
ordinary transaction or business. 

In compliance with this law, there may certainly cases arise in which the 
physician is subjected to a very great amount of labour, inconvenience, and 
even detriment to his regular business, without any return that can be called 
a remuneration; but he is liable to this only as is every member of the com- 
munity liable. A surgeon is called to a case of injury inflicted by one indi- 
vidual upon another, from which death results; as a consequence, he is cited 
first before the coroner's jury, then before the grand jury, and finally before 
the supreme court. Much time is expended in these attendances, and the re- 
muneration is next to nothing. He has not, however, any legitimate ground 
of complaint; his knowledge of the facts in this case was the consequence of 
his profession; he felt obliged to attend when his services were originally re- 
quested, and his duty to society compels him, in like manner, to give his 
testimony when that is demanded. The case is undoubtedly a dead loss to 
him in a pecuniary point of view, but it is a loss equivalent to which every 
passenger by railroad, or steamboat, or in the street is liable, since he may be 
the unwilling spectator of an accident or murder requiring legal investigation. 
In the fact of his attendance in the court of justice then being compulsory, 
the physician has no greater cause of complaint than any other citizen. The 
public have a right to his testimony; that he has been placed in a situation to 
give this testimony is the consequence of his profession, and his liability to 
this annoyance, if it be an annoyance, should have been considered when he 
adopted it. 

It may sometimes happen, it is true, that a medical man is entrapped into 
the examination of a case which he afterwards discovers involves a legal in- 
vestigation. As, for instance, a patient has, or thinks he has, been maltreated 
by a practitioner whom he has employed, the case being generally one of injury, 
and he consults another ostensibly for the deformity, which is the result of 
the accident, and with the view of its possible remedy : the second surgeon 
soon discovers that he is summoned as a witness in a trial in which the first 
surgeon is defendant and the patient the plaintiff. Now, the trap in which 
the unfortunate surgeon has been caught was certainly not laid for him by the 
law. If his suspicions had been excited, it would have been perfectly justi- 
fiable for him to decline to examine the seat of the injury, or to state that 
he should demand a fee proportionate to the trouble, &c., which the case 
involved; it would be also perfectly justifiable that he should demand a fee, 
on the ground that his decision to the patient would decide the commence- 



1852.] Parkmaiij Relations of tlie Medical Witness vntli the Law. 



129 



ment or abandonment of a suit, as a lawyer is paid for the examination of a 
case, to see if an action is likely to be successful; but, having omitted to do 
this, he stands in the same position as the witness to any other transaction, 
and the law is not responsible. 

Let us now examine whether on the witness stand the medical man is 
subjected to any worse treatment than any other witness from the other classes 
of society. 

Now, the method which has been adopted in this country, derived from our 
English ancestry, is the trial by jury. As a consequence of this, the appear- 
ance of witnesses on the two sides of the case is rendered necessary, from 
whom the truth is elicited, or attempted to be elicited, by an examination 
made by the lawyer of the summoning party, and a cross-examination made 
in a similar manner by the opposite party, which is intended as explanatory 
of the first. It is quite possible that this may not be a perfect method of arriv- 
ing at the truth, still it is the one adopted, and probably is liable to as few 
objections as any other that could be proposed to be applied in all cases; at any 
rate, it is the one to which all are subjected, and the medical man has no 
right to claim an exemption. 

Now, in proportion to the seeming importance of the witness to one side, 
must be the severity of his cross-examination by the other, and this cross- 
examination will of course be directed to the detection of flaws in the testi- 
mony already given. A medical witness has no prescriptive right to expect 
that his dicta are to be taken on the stand merely on his own authority; his 
reasons must be asked, and he must be prepared to defend them ; and if, as 
must happen in certain cases, the value of the evidence is dependent upon the 
capability of the witness to make an accurate observation, he must not consider 
it an imputation to be resented, if he be questioned not only as regards the 
grounds of his opinions, but also on his means or opportunities of having 
acquired the power of forming an opinion. Thus, if testimony were being 
given with regard to an accident to a limb, where from the nature of the case 
the diagnosis, from its acknowledged obscurity, required an accurate knowledge 
for its formation, questions directed towards these points could not be ob- 
jected to, for, although the jury may be perfectly incapable of understanding 
the questions put, still, by the answers made, they can form a very good opinion 
of the value of the testimony given. In fact, this cross-questioning may really 
be considered as an advantage to the witness who is competent to testify, as it 
marks the difference between him and the incompetent one. It is true that 
this examination into the capability of a medical witness is often conducted 
in a manner somewhat annoying, but, perhaps, it may be well to distinguish 
how much of this annoyance arises from the natural disinclination, which 
every one feels, to have his ability to judge of any fact in his profession ques- 
tioned, and then it may be found that the inquiry is conducted generally as 
fairly as possible. At any rate, the process is one to which all witnesses are 



130 ParkmaD; Relations of the Medical Witness with the Law. [Jan. 

subjected, and amounts to nothing more than asking a witness, who testifies 
that he has seen something at a distance, as regards the power of his vision. 

Allied to this kind of cross-examination, is one of which medical men often 
complain, viz., where, by the ingenious statement of hypothetical cases, ques- 
tions upon the evidence already given, and like devices, an attempt is made 
to confuse the witness, or to cause him to detract somewhat from the positive 
character of his previous testimony. This kind of examination all ranges 
itself, however, under that just alluded to, and is in fact directed towards the 
examination of the capabilities of the witness to form an opinion or judgment. 
And in truth those qualities of mind which enable one to arrive at correct 
judgments and opinions are precisely those which fit him to pass with credit 
to himself, and with usefulness to the court, through the ordeal of the cross- 
examination. In testimony upon all scientific subjects, apart as they are 
from the usual routine of the business of society, and pre-eminently so in 
that upon medical subjects, the jury are obliged to take the evidence upon 
trust, and this trust must be founded upon the character of the mind of the 
witness as it is elicited by his cross-examination. If, in his testimony in chief, 
he has been making broad and ill-defined assertions, he cannot expect that 
his reputation with the jury for judgment and discretion should not be 
damaged if he is obliged to retract or limit them; neither can he complain if 
advantage be taken by counsel of such circumstances. The jury are in- 
fluenced in their judgment of the medical testimony very much as the public 
are influenced in their opinion of medical men, viz., by their conduct and 
action in the general afi"airs of life. Thus, the jury cannot judge of medical 
evidence as such, but they can tell when a witness is obliged to contradict 
himself, or to retract from a position once taken ; and such circumstances 
must necessarily have weight with them. Furthermore, it must be remem- 
bered that, although the lawyer has this power of cross-examination, still he 
is restrained by many circumstances in its use — by his necessary ignorance 
of the subject, for example, and more especially by his fear lest the answers 
may be such as to confirm the examination in chief, and thus strengthen the 
hands of his adversary. In fine, it may well be doubted whether any 
advantage would ever be obtained over a medical witness, if it were not for 
some error or mis-statement of his own; and any one who has watched cases 
involving medical testimony would not find it difficult to cite examples 
where, if the counsel had been a physician, he would have detected errors 
made by medical witnesses which have passed unnoticed. 

It may appear a curious subject of inquiry, why medical men, who are 
in the constant habit of weighing evidence, and giving opinions on the result, 
should be so liable to break down when they come to be examined in a court 
of justice; and perhaps a solution may be found in the following considera- 
tions : A medical man, in coming to a conclusion which is to influence his 
action in any particular case, is seldom so fortunate as to be certain that he 
is clearly right; he only knows that, all things considered, he is taking the 



( 



1852.] Parkman, Relations of the Medical Witness with the Law. 131 

best course. In an extreme case death, without something be done, being 
certain, a course of treatment is adopted which is believed to be the most 
likely to prevent this termination : but it is evident that the foundations of 
this opinion need not be so strong as they ought to be, where the opinion 
leads, as it often does in a court of justice, directly in the opposite direction, 
viz. from life to death. In the one case, action might be taken on very 
slight grounds ] in the other, nothing short of a logical certainty is satisfac- 
tory. Medically, a physician feels sure of many of his principles, this assur- 
ance amounting by no means, however, to a logical conviction; and the dis- 
tinction between the two is what the medical witness oftenest overlooks, and 
which oversight oftenest trips him up. A medical opinion to a patient has 
this in it which is worthy of remark, that the course of conduct recommended 
should have its proper effect ; it should be given with an air of a certain 
authority, stating all the affirmative, and somewhat overlooking the negative 
side. A decision of some kind is almost as important to the patient as that 
it should be exactly the right one ; the medical man, therefore, often states 
confidently when in reality he has no grounds for any extreme confidence, 
except that the appearance of it is better for the patient. The patient is to 
be advantaged by the physician's confidence, the criminal should have the 
advantage of his doubts; and to elicit these, which the medical witness is 
constantly tempted to overlook, is the object of a cross-examination. To 
conclude, then, this portion of these remarks, it will be seen that the medical 
man has no cause of complaint that he is subjected to any peculiar treatment 
in a court of justice; that the inconveniences which he suffers are the conse- 
quences of his position as a citizen; and that he will pass through his exami- 
nation with credit to himself if he divest his mind of all unnecessary fear, 
and remember that the cross-questioning cannot be severe unless from his 
own over-confidence and mis-statement. 

We arrive now at the consideration of the second portion of our inquiry — 
the position of the physician when present in the court of justice as an 
expert. 

That the opinion of a physician should be asked, implies that it is of 
importance in the decision of the case — and so far it is a compliment to him; 
and if he undertakes to give it, he assuredly cannot complain if he be called 
upon to defend it against the cross-examination. If an engineer gives an 
opinion upon the construction of a light-house, or any other public work, he 
expects that this opinion will be canvassed and subjected to the test of 
examination by the party employing him ; and, moreover, he expects that 
many groundless objections will be brought against it, and perhaps even 
unfair attempts made to make particular points appear weaker than the 
reality. This labor he voluntarily undertakes, and he must abide by the 
consequences. But is the position of an expert in a court of justice one 
which he can accept or decline as he may please ? It is clear that any wit- 
ness may be summoned whom counsel may say is necessary for their case; 
No. XLY.— Jan., 1852. 10 



132 Parkman, Relations of the Medical Witness ivitli tlie Law. [Jan. 

and when thus summoned^ may not an opinion be elicited by questions put 
for the purpose? A compulsory power of this kind evidently cannot exist, 
and for several reasons: 1st. From the impossibility of its exercise: it 
would be impossible to make a witness hear the evidence in a case, and then 
give an opinion upon it. He may be cited on the stand, and when asked if 
he has heard the evidence, reply in the negative; of course, then, he will 
have no opinion to give. It would be still more impossible to make him do 
an act by which an opinion might be formed, as to examine a case, to make 
an autopsy, or a chemical analysis. A physician's opinion is the result of 
his education; his education is the result of his time and money expended in 
its acquirement; and an individual has no more right to extract it from him 
on the witness stand than in his own office. 2d. This point has not been 
left undecided by the law. In the English courts (1 Carrington & Kirwan, 
N. P. 23, Webb v. Page, March, J.) it has been ruled that the testimony of 
an individual cited as an expert is voluntary, and he may decline to give it, 
if it so seem fit to him. A decision, so manifestly just would undoubtedly be 
maintained in this country, if at any time any physician or other scientific 
person cited as an expert should wish to make the trial. It results, then, 
that no physician, unless he choose, need give testimony as an expert ; and 
the remuneration which he may demand is of course to be regulated by his 
other and similar professional charges; and the expert may always be sure 
that his remuneration will be gladly and willingly paid by the party employ- 
ing him, since it is often his evidence which makes the turning point of the 
case, and is of the chiefest importance. That physicians are often used as 
experts without pay cannot be denied; but it is no less true that their ser- 
vices in other instances often go unrewarded, even by those who should blush 
to permit it. This is in a degree the fault of the physicians themselves, and 
in a degree the consequence of circumstances too numerous to mention at the 
present time. My purpose will have been attained, if I have shown that 
the practitioner of medicine has no cause of complaint against the law or its 
ministers. To make himself respected, and to be successful as a witness, the 
physician has only to maintain that deportment and bearing of manner, and 
circumspection of his opinions, which would gain him credit elsewhere. And 
to obtain his rights — by which is meant a just remuneration for his services — 
he has only to understand them. 

In these brief remarks, I have touched only upon the relation which the 
medical witness bears to the lawyer who is to question him, as the representa- 
tive of the law. I have desired to show that there is no necessary antago- 
nism between the two, and that, although the position of the one who is the 
questioner naturally places him in a relation somewhat annoying to the other 
who is the questioned, still, that this is in the line of his duty, and the an- 
noyance is one unavoidably connected with the organization of our courts of 
law, as a means of arriving at truth, rather than one capable of removal. The 
ordeal of cross-examination is one to which all classes of witnesses are alike 



1852.] Parkman^ Relations of the Medical Witness ivith the Law. 133 

subjected; and it is a matter for consideration, whether the fact that physi- 
cians are so loud in their complaints of its severity and unfairness may not 
in a degree be attributable to their own sensitiveness to questions, even for 
the grounds of their opinions. 

There is one other position in which a medical man may find himself placed 
with regard to the law — and it may not be without interest to examine the 
views which should influence his course of action. It may happen to any one 
to be called upon to treat a case in which he suspects the symptoms to be 
caused by poison administered previously. It is well known, for example, 
that cases of poisoning by arsenic are often treated as cases of cholera, or 
some other form of intestinal disturbance, and that certainty cannot, in fact, 
be arrived at unless from a post-mortem chemical examination of the contents 
of the stomach, &c. A physician connected with a case of this kind is in a 
somewhat unfortunate position, it is true, and has need of considerable judg- 
ment to decide upon his best course of action. If only his own case and com- 
fort were consulted, he would maintain a discreet silence as regards his suspi- 
cions, and be careful of exciting in any degree those of others. In doing so, 
however, he would most assuredly be false to his duty as a citizen, v/hich re- 
quires of all to inform of suspected crimes, under penalty, in some circum- 
stances, of being considered an accomplice after the act. Duty requires the 
declaration. It remains, however, for consideration how it shall be done to 
avoid on the one hand the exciting an accusation which may prove to be 
groundless, and on the other, to furnish the testimony, if it shall be required, 
in such a manner as to make it available to the government. 

Under these circumstances, the best course of the physician would seem to 
be" to consult at once the legal officer, whose duty it will be to prosecute in 
the case, to state the suspicious circumstances, insisting at the same time upon 
the necessary uncertainty, and giving this as a reason for the unwillingness 
to make a direct complaint. With these premises, the legal officer would 
give advice upon the technical points necessary to be observed that the 
chain of evidence may be complete, provided it should be found necessary to 
test its strength : directions upon these points should be asked to be clearly 
given, and then should be followed so accurately that the important points 
maybe sworn to in the court of justice. By management of this kind, which 
is in fact only placing the responsibility in its true place, the legal officer 
would strengthen the hands of the physician against any flaws which might be 
picked by an acute counsel in his testimony, which, arising from a perfectly 
excusable inadvertence, might place him in an awkward and embarrassing 
position. The physician who had thus cautiously felt his ground, and never 
advanced till he was sure of its firmness, would, when he came to the stand, 
win the confidence both of judge and jury, and would gain for himself there 
a reputation for sound sense and discretion which a similar careful proceeding 
always induces in other positions in life. Whereas, if, on the contrary, he 
should wait till he was perfectly satisfied himself before he made any mention 



134 Garrison^ Case of Ossification of the Placenta. [Jan. 

to the legal officers, he would place himself in a false position in several ways; 
as, for instance, he thus virtually undertakes to vouch to the prosecuting 
officer that no one of those minute and technical points has been omitted in 
collecting the evidence, which, although without weight in the formation of 
his own belief, might be just the connecting link to bind the whole testimony 
together. In the investigation of every case of this kind, there are certain 
little particulars liable to be overlooked, because without influence in the 
formation of our own belief; and yet which may be of the utmost importance 
in giving that certainty to the testimony as to render it convincing to twelve 
jurors, which certainty the accused has a right to demand; and an oversight 
of this kind, thus actually defeating the ends of justice, might very much 
injure the reputation of a medical man. In a word, by careful proceeding 
under these circumstances, the physician places a responsibility, which in truth 
does not belong to him, upon the shoulders which should assume it, viz., those 
of the legal officer, and makes himself simply a witness in the case. If such 
a course as this had been followed in several cases to which allusion might be 
made, much unpleasant bickering and recrimination might have been spared. 

The substance of the above has been suggested by views brought under my 
notice lately, both in public and private, and it has seemed to me to have a 
certain amount of importance. A lawyer of some distinction, in commenting 
to me upon the very improved character of the medical testimony given within 
the last few years, regretted at the same time the jealous suspicions that often 
appeared to influence physicians when on the stand ; and said that, having had 
occasion often to question medical men, he always approached it with some fear, 
lest his questions might betray his ignorance; and always with the knowledge 
that any attempt of oppression on his part could never be successful, provided 
the witness used a very little care and circumspection in his replies. A medical 
witness will, therefore, most assuredly appear the better upon the stand if he 
consider himself there not as a professional man set apart from the rest of 
society, but as about to fulfil a duty which is incumbent upon him as a citizen; 
and that the same conduct which gains him credit elsewhere will insure it 
there. I have desired to disabuse the minds of my medical brethren of what 
I conceive to be an error — and I believe that, if I am right, more service will 
be done than by a bigoted fostering of prejudices which here, as everywhere 
else, are the parents of much evil. 



Art. IX. — A Case of Ossification of the Placenta, occurring several times in 
the same Individual. By Charles G-arrison, M. D., Swedesboro', New 
Jersey. 

Most of our writers on obstetrics have treated at some length on the sub- 
ject of retention of the placenta, its causes and efiects; but I have not been 



1852.] Garrison, Case of Ossification of the Placenta. 135 



able to find in any of them a satisfactory account of that form of retention 
which is caused by ossification of the uterine surface of the placenta. It is, 
however, eminently deserving our attention, both from the interest which 
attaches to the questions relating to the reasons and mode of its production, 
and from the formidable nature of the difficulties and dangers to which it 
may give rise in actual practice. These latter are well illustrated in the fol- 
lowing case, which, although constituting my entire experience on this point, 
has, nevertheless, been so peculiar in some of its features, that it may serve 
to add a little to our yet small stock of information upon this subject. 

On the 25th of October, 1835, I was called to attend Mrs. J. H., in her 
second confinement. She stated to me that, in her first labour, which had 
occurred some three years previously, there had been great difficulty, particu- 
larly with the placenta; that the physician in attendance had been obliged to 
send to Philadelphia for Dr. Meigs, who ultimately delivered it, though with 
great pain to her and apparent difficulty to himself, and not till after the oc- 
currence of considerable hemorrhage. What had been the nature of the 
obstacle she did not know. 

On examination, I found the presentation favourable, and the labour na- 
tural; the child was rapidly pushed down, and in about four hours the deli- 
very was accomplished. After the birth of the child, I applied my hand to 
the abdomen, and felt the uterus strongly contracted into a ball of the ordi- 
nary size, and began to think that, whatever untoward accident might have 
complicated the former labour, there was not likely to be any trouble with this. 
But in about ten minutes there was a tremendous gush of blood, which was 
quickly followed by another quite as large as the first, the result of which 
was great and almost fatal prostration; the pulsations at the wrist were scarcely 
felt, the face became pale, the hands cold, and the respiration sighing; she 
grew sick and vomited, complained of being very cold, pushed down the bed- 
clothes, gasped for breath, and in a very short time after the last discharge 
was in a profound syncope. In the mean time, I had poured a pitcher of iced 
water, which was previously prepared, over the abdomen, and introduced my 
hand into the uterus, quickly and without any obstacle, as the hemorrhage 
had produced complete relaxation of both the uterus and the external parts; 
but on reaching the placenta, and attempting to introduce my fingers between 
it and the uterus, for the purpose of effecting its detachment, I found it im- 
possible to do so, as the union between them seemed perfectly firm and un- 
yielding. After a moment's consideration, I determined to make a separation 
at all hazards, if it was possible, as death was inevitable if the placenta should 
be long retained. I began the operation slowly and cautiously, as the sepa- 
ration could only be accomplished by actually tearing or scratching the 
placenta from the surface of the womb, which could not be done except by the 
exertion of considerable force, more than it seemed possible that she could 
survive; and it was accompanied by a kind of crackling noise, which was heard 
distinctly both by myself and the attendants at the bedside. I soon found 
that I must hasten the delivery, or the patient would die before it was effected, 
and, letting go the cord, I placed my hand over the outside of the uterus, 
and, as rapidly as I was able, proceeded to loosen the placenta from its attach- 
ments. In this manner I succeeded in separating the whole mass, though in 
detached portions, which, together with my hand, were soon expelled by a 
smart contraction of the uterus. But although I had succeeded in removing 
the placenta, I still felt extremely anxious about the patient; she was yet in 



136 



Dalton, Case of Poisoning with Oil of Tansy. 



[Jan. 



a state of complete unconsciousness. I gave her a large dose of opium, ap- 
plied ice to the abdomen, and kept up frictions over the outside of the uterus 
till it was firmly contracted and all hemorrhage had ceased. She roused up 
for a moment, but the syncope immediately returned, and it was a considerable 
length of time before she showed any persistent signs of reviving animation. 

On examining the placenta, I found all that surface of it which came in 
contact with the uterus in a state of ossification ; it presented, through a com- 
mon pocket glass, a kind of cellular arrangement, similar in appearance to 
what might be produced by sticking the whole surface full of the husks of 
wheat which had been broken in two, leaving the broken edge of the husk 
turned outward. It was undoubtedly the separation of this bony matter which 
gave rise to the crackling noise which had been heard during the process of 
delivery. I could reproduce the same sound in the placenta after it was ex- 
pelled \ it crackled in my fingers like frozen grass or ground. I had never 
upon any previous occasion been compelled to use an equal degree of force 
in the delivery of the placenta, and I felt very doubtful as to what might be 
the issue of it; the utmost strength of my fingers was barely able to break 
up this bony union. 

Since this time I have attended Mrs. H, in five confinements^ and in all but 
one there was a similar condition of the after-birth, accompanied by similar 
phenomena of excessive flooding and great difficulty of separating the bony 
surfaces of the uterus and placenta. In that one, her fourth labour, I did 
not reach her till the child had been delivered by a midwife, who, in her 
zeal to complete the labour before my arrival, by removing the after-birth, 
had pulled so hard upon the cord that she had torn it quite away, leaving 
the placenta still within the womb; but in this instance there was not any 
hemorrhage, which led me to hope that it was merely a case of ordinary 
retention, without any formation of ossific matter, and on the introduc- 
tion of my hand, I was pleased to find that my conjecture had been right. 
The placenta was easily detached and soon expelled; had there been the same 
difficulties here as in all the other labours through which I attended her, 
she must, in all probability, have lost her life before she could have been 
delivered. 

Her last labour occurred about two years since, accompanied with the same 
circumstances as had characterized the other instances in which bony adhesions 
had taken place. I did not reach her until after the birth of the child, and, 
although the placenta was delivered as quickly as was possible in so difficult 
a case, yet the amount of hemorrhage had been such before my arrival, that 
for many hours I altogether despaired of her recovery from the terrible syn- 
cope which it had induced; but, under the use of large and repeated doses of 
opium, she at length revived, and soon regained her usual amount of strength. 



Art. X. — A Case of Poisoning with Oil of Tansy — Death at the end of 
three hours and a-half — Quantity of the Drug taken about a7id '^iii. 
By John C. Dalton, Jr., M. D. (Read to the Boston Society for Medical 
Observation, June 2d, 1851.) 

E. S., a fine, healthy-looking girl, about twenty-one years of age, died at 
the house of Mr. A. in Boston, on "Wednesday, the 7th of May, 1851. She 



1852.] Dalton, Case of Poisoning with Oil of Tansy. 



137 



had been employed in Mr. A.'s family as a seamstress since some time in the 
previous winter, living in the house during the week, but going away on 
Saturdays to a cousin's in Pleasant Street, and returning to Mr. A.'s on 
Monday morning. She had been for some months receiving the attentions of 
a young man who was reputed to be engaged to her. None of her friends, 
however, suspected anything to be wrong with her until Mondaj^, May 5, 
when her cousin, with whom she had been spending Sunday as usual, per- 
ceived the odor of tansy in the room which she had occupied; w^hereupon it 
occurred to her that the girl might have become pregnant, and used the drug 
for the purpose of producing abortion. 

On Tuesday, she was engaged in her ordinary employment, and dined 
heartily a little after five o'clock in the afternoon. She went up stairs to her 
room about half-past nine o'clock. The cook, who occupied a room above, 
went up with her and stopped in her room, conversing, for some fifteen mi- 
nutes. The girl's manner was perfectly natural and cheerful, as it had been 
throughout the day. About a quarter before ten o'clock the cook left her 
preparing for bed, and went up to her own room. 

Nothing more was heard from her till about eleven, when Mr. and Mrs. A., 
who were sitting in the basement-room, heard a scream, w^hich they supposed 
to come from one of the children. Mrs. A. went immediately up stairs, and 
on entering Miss S.'s room found her on the floor, by the side of the bed, 
insensible and in violent convulsions. She had evidently fallen out of bed, 
as she was undressed, and the bedclothes were disturbed, and had been par- 
tially dragged on to the floor with her. Dr. Morrill was immediately sent for, 
and arrived in about ten minutes. He sent also for me, and I arrived at the 
house at half-past eleven o'clock. 

The girl was then lying on her back by the side of the bed, and presented 
the following appearances : Total unconsciousness ; cheeks flushed, of a bright 
red colour; eyes open and very brilliant; pupils of equal size, widely dilated 
and immovable; sclerotics injected; skin warm, not remarkable as to moist- 
ure; respiration hurried, laboured, stertorous, and obstructed by an abund- 
ance of frothy mucus, which filled the air-passages, and was blown from be- 
tween the lips in expiration ; the breath had a strong odour of tansy, as had 
been already observed by Dr. Morrill; pulse quite full, forcible, 128; at in- 
tervals of five to ten minutes the body was convulsed by strong spasms, in 
which the head was thrown back, the respiration suspended, the arms raised 
and kept rigidly extended, and the fingers contracted. After this state of 
rigidity had continued for about half a minute, it was usually succeeded by a 
tremulous motion, often sufiicient to shake the room, together with very fuint 
and imperfect attempts at inspiration. The whole interval, from the com- 
mencement of the convulsion to the first full inspiration, varied from a minute 
to a minute and a-half. Occasionally, the tongue was wounded by the teeth, 
and the saliva slightly tinged with blood. Immediately after a convulsion 
the countenance was very pallid and livid, from the suspension of respiration, 
and the pulse exceedingly reduced in strength and frequency. The pulse and 
colour then gradually returned until the occurrence of the next spasm. It 
was very common, a few seconds after the termination of a convulsion, for the 
head to be drawn slowly backward, and the eyelids, at the same time, stretched 
wide open. In the intervals of the convulsions, the limbs were mostly relaxed, 
but the jaws remained clenched. 

A vein was immediately opened in the right arm, and about Oij of blood 
taken away. After this, the pulse became much softer and the face lost its 
bright colour. There was, however, no change in the condition of the pupils, 



138 



Dalton, Case of Poisoning with Oil of Tansy. 



[Jan. 



nor return of consciousness, nor other improvement in the appearance of the 
patient. It being impossible to get anything down the throat, two injections 
of an ounce of wine of antimony, with about Jss of powdered ipecac, were 
thrown up the rectum at intervals of about half an hour^ but produced no 
apparent effect. 

On searching the room, a gij phial was found in the pocket of the girl's 
dress, wrapped in a piece of paper, labelled Oil of Tansy," and marked with 
the name and address of an apothecary in Pleasant Street. The phial con- 
tained 5v of oil of tansy of the ordinary purity. A mug was also found, from 
which she had apparently drunk the oil mixed with water, as it smelt very 
strongly of the drug, and still had a drop or two of it at the bottom. 

The condition of the patient continued much the same for about an hour. 
The convulsions, however, gradually became less protracted, and the failure 
of the pulse after each attack more complete, at the same time that it reco- 
vered strength less perfectly in the intervals. The countenance also became 
somewhat sunken and the temperature of the skin reduced. About one 
o'clock, six leeches were applied to the forehead and temples, and sinapisms 
put on the calves of the legs. The leech-bites bled freely. 

Towards two o'clock the alteration for the worse became quite rapid. Pulse 
124 and feeble; respiration 36, and attended with less muscular effort than 
at first; the left cornea was glazed, but the right continued brilliant; a little 
inward strabismus of the right eye, and the mouth and nose drawn a little to 
the right side. Occasionally, a slow, lateral, rolling motion of the eyeballs. 
At five minutes past two she had the last convulsion, which was much less 
violent than the earlier ones, and lasted only half a minute. There was no 
recovery of the pulse after this attack, and she died at a quarter-past two 
A. M. 

Autopsy ten hours after death. 

Countenance natural ; cadaveric rigidity very strong; only slight purplish 
discoloration of dependent parts; no ecchymoses anywhere; no effect had 
been produced by the sinapisms on the legs. 

Bead. — Scalp not injected; distinct, but not excessive dryness of arachnoid 
over hemispheres of brain; no effusion, congestion, or other unnatural appear- 
ances anywhere about encephalon. 

Chest. — Heart and pericardium natural; left ventricle firmly contracted; 
blood everywhere unusually fluid ; interior of heart exhaled a distinct odour 
of tansy, as also cut surface of pectoral muscles. 

No alteration of pleura; lungs rather shrunken, crepitated perfectly every- 
where, and were not at all engorged; air-passages not remarkable except for 
a little redness of posterior surface of epiglottis. 

Abdomen. — Strong odour of tansy in peritoneal cavity ; a few drachms of 
thin fluid in pelvis ; peritoneum natural in appearance. 

OEsophagus natural internally, except that epithelium was somewhat defi- 
cient in lower part. 

The stomach contained about ^xij of a semifluid, yellowish-gray substance, 
consisting of partially digested food, potato, cranberries, onions, &c., mixed 
with an abundance of small, brownish-yellow, glistening oil globules, and 
exhaling an excessive odour of tansy; mucous membrane generally pale, not 
vascular in any part, but throughout nearly the whole of great pouch brown- 
ish and much thinned and softened, so that for a considerable space it is 
nearly or quite destroyed. There was an old, whitish, slightly puckered 
cicatrix of the mucous membrane on posterior wall of stomach, near small 
curvature. No other morbid appearance. 



1852.] 



Dalton, Caze of Foiwning with Oil of Tansy. 



139 



The lacteals of the mesentery were very distinct, and distended with milky 
chyle. 

Small intestines were natural internally throughout. They contained, at 
their upper part, pasty masses of dusky-coloured chyme, mixed with oil of 
tansy. 

Below, the contents were less abundant, and were unmixed with oil. 

Large intestine contained yellowish feces, and small masses of a brownish 
powder, apparently ipecac. Mucous membrane natural. 

Spleen rather shrunken, flabby, and deficient in blood. Other abdominal 
organs not remarkable except for slight paleness. 

Urinary bladder contained ^ii to ^iii of urine. 

The uterus was enlarged, so that its upper edge came two and three-quai-ter 
inches above level of symphysis pubis. It contained a well-formed female 
foetus, about four months old. 

There was not the least appearance anywhere of the foetus or membranes 
having suffered any disturbance. 

The left ovary, which hung down a little lower than the right, had near its ex- 
ternal extremity a small conical prominence, where the fibrous coat was wanting, 
and its place occupied by peritoneum alone. There was a very slight appear- 
ance here of a cicatrix, visible only on close inspection. There was no unusual 
vascularity here, or at any other part of the ovary. Beneath this prominence 
the corpus luteum could be felt through the ovarian tissue, tolerably firm and 
well defined, and having the form of a sphere, compressed laterally, much 
like that of the crystalline lens. On dividing the ovary longitudinally through 
the prominence, the corpus luteum was exposed. It presented a nearly cir- 
cular section, measuring seven-eighths of an inch in its long diameter, and 
three-fourths of an inch in its short. It consisted externally of a convoluted 
wall, of a dull-yellow colour, measuring at its deepest part a little over three- 
sixteenths of an inch in thickness. The space enclosed by the yellow wall 
was occupied by a colourless, reticulated, fibrinous coagulum, which possessed 
a few minute vessels. This central coagulum was much compressed laterally; 
so that, although it presented a cut surface of about half an inch in diameter, 
it had hardly more than one line in thickness. There was no cavity nor 
fluid anywhere. 

Both ovaries were carefully divided in every direction, but only one other 
body was found having any resemblance to a corpus luteum, and that was so 
small and imperfect as to be hardly recognizable. There were many Graafian 
vesicles in the interior of each ovary, varying in diameter from three-sixteenths 
of an inch downward, but none at all prominent on the surface. Both ovaries 
were quite healthy. 

It was subsequently ascertained that the oil of tansy was obtained, at the 
shop of the apothecary whose label it bore, on the evening of Friday or Sa- 
turday preceding the girl's death. The apothecary's clerk, who recognized 
the bottle, testified at the inquest that he put up in it ^ij of oil of tansy, and 
delivered it to a girl about fourteen years old, who stated that the family that 
sent for it wished to take it into the country. The patient, therefore, un- 
doubtedly took ^i and Jiij of the drug. It seems probable that the violent 
action of the poison commenced at eleven o'clock, at the time the family 
heard the patient scream ; and if we allow fifteen minutes for the absorption 
of the oil after it was swallowed^ it would give three hours and a-half from 



140 



Kelly, Case of Puerperal Fever. 



[Jan. 



the time of taking the drug till the patient's death. Fifteen minutes may 
seem rather a long time for the operation of a volatile oil to be delayed, but 
it is probably no more than should be allowed. In a case which recently 
came under the notice of Dr. Dalton, of Lowell, a girl took a quantity of oil 
of tansy just before dinner. She then went into the dining-room, sat some 
time at the table, ate with apparent relish, felt sick, left the table, went into 
the yard, vomited what she had eaten, and immediately fell down insensible 
and convulsed. She recovered, after remaining a long time unconscious. 
The only other recorded fatal case of poisoning with this oil that I am 
acquainted with also occurred in Boston, under the care of Dr. C. T. Hil- 
dreth, and was published in the American Journal of Med. Sciences for May 
1835. In that case, the woman took gss of the drug, and did not lose con- 
sciousness entirely till three-quarters of an hour afterwards, though she was 
convulsed at intervals before that time. After unconsciousness became com- 
plete, she did not again recover it, and died rather less than two hours after 
taking the poison. 

The present case is another instance of the extreme violence to which the 
system may be subjected even in the early months of pregnancy, without in- 
ducing abortion. Though all the muscles, both of the body and limbs, were 
for three hours and a quarter subjected to a succession of the most violent 
contractions, there was no sign of abortion, and after death the ovum was 
found in the uterus entirely undisturbed. In Dr. Hildreth's case also, preg- 
nancy existed but a few weeks advanced, and the drug was undoubtedly taken 
for the purpose of producing abortion, but nothing of the kind took place. 
The general symptoms in that case were similar to those described in the fore- 
going, the most remarkable difference being the more gradual loss of con- 
sciousness, and the more rapid death after a much smaller dose. 



Art. XI. — Case of Puerperal Fever treated successfully with Opium in 
large Doses, By Wm. Kelly, M. D., Resident Physician to Blackwell's 
Island Hospital, New York City. 

The following case of puerperal fever, treated successfully with opium, may 
be of interest to the readers of the Journal, not so much perhaps from the 
novelty of the plan of treatment that was adopted, as from the larger quan- 
tities of the drug that were required to produce the effects desired. 

Mary B., spinster, aged twenty-four, healthy, was delivered of her first 
child in this hospital in the morning of the 14th December last. The labour 
had been a tedious one of thirty-six hours' duration. Through the latter por- 
tions of it I had attended her. There had been no case of puerperal fever in 
the house for months. There were, however, at the time two cases of erysi- 
pelas in an adjoining ward, and I had been in attendance upon them. 



1852.] 



Kelly, Case of Puerperal Fever. 



141 



On the morning of the 15th, four o'clock A. M., twenty-four hours after de- 
livery, she suflfered a severe rigor. At five o'clock I was called, found her 
with an anxious face, deep sighing, a pulse of 120, small and hard, pain and 
tenderness in the right iliac region over a space as large again as the palm of 
the hand. The lochia had ceased ; the secretion of milk had not yet com- 
menced. 

Inasmuch as the usual plan of treatment by depletion, by calomel and 
opium, by fomentations and blisters, had been repeatedly tried in this 
hospital, and the Almshouse, and in other hospitals under my observation, 
with results by no means satisfactory, I resolved to give this patient the 
full benefits of an opium treatment. I felt that I had no chance of life to offer 
her out of this. It had been recommended by a friend of eminent ability 
and great judgment, who had tried it with success in a number of cases during 
the past season. I considered the main indication in the case to be to allay 
irritation J which otherwise would be sure to aggravate the disease, and exhaust 
the patient. I determined to keep the system as insensible to the presence 
of the disease as was compatible with the continuance of life and the due 
performance of the functions of the body; besides this, little or nothing was de- 
signed in the way of treatment. It should be left to nature to cure the disease 
after the obstacles that lay in the way of her doing so had been removed as 
far as was in our power. The success which attends the almost pure opium 
treatment of dysentery, the great benefits derived from the free adminis- 
tration of this medicine in exhausted conditions of constitutional syphilis, and 
in very many other diseases, had, by analogy, recommended this mode of 
treating puerperal fever at its first suggestion. The result was most entirely 
satisfactory : within nine days of the accession of the fever, ushered in with the 
surest symptoms, she was well. Within this period she had taken ten 
grains of morphia, applied to a blistered surface, eighty-four grains by the 
mouth, besides seventy grains of opium. For six days she took twelve grains 
of morphia daily. She was seen every hour either by myself or by Dr. Jen- 
kins, the assistant physician. The quality of the article was good. It was 
tested by giving one-eighth of a grain to a patient known to be very suscep- 
tible to its influence. In her it produced semi-narcotism for twelve hours. 
No function seemed to be injuriously affected by these large doses. Indeed 
the bowels were kept in a relaxed condition. The kidneys performed their 
office as usual. 

The hospital records furnish the following history of the case : — 

At the first visit, five o'clock A. M., December 15th, patient being 
in the condition described previously, one teaspoonful of laudanum (this 
being on hand) was administered and repeated within twenty minutes. After- 
wards three grains of powdered opium were ordered every half hour till 
profound sleep should be produced. 

7 o'clock, P. M. Pulse 150, quick, hard, and small; pupil contracted; 
patient sleeps, but not profoundly; is easily roused; the whole body is bathed 
in perspiration; abdomen tympanitic, still tender in right iliac region. 
Ordered a blister twelve by twelve over abdomen. 

12 P. M. Condition the same. Up to this hour patient has taken Jj of 
opium; soon after this, vomiting occurred, and probably the most of the opium 
administered between this and morning was rejected. 

Dec. IQtli, 6 A. M. Pulse 120, fuller and softer; less sighing; lochia not 
returned; breasts painful; manifests no concern for child; vomiting still 
continues; tympanitis gone; abdomen vesicated. Ordered two grains of mor- 
phia to be sprinkled over the blistered surface every two hours. At night 



142 



Pratt, Cases of Delirium Tremens. 



[Jan. 



morptiia in solution being tried and retained bj the stomach, it was directed 
to be given, one grain every two hours, or in such quantities as to produce 
sleep. By an oversight the order for the external application was not counter- 
manded, consequently the patient got by six o'clock P. M. six grains of the 
sulphate of morphia internally, and ten grains externally. At seven, she 
was found somewhat narcotized, pulse 120, respiration seven in a minute and 
gasping; pupil contracted to the smallest point ; yet patient did not sleep; 
said she could not get her breath ; heard all that was said in the ward ; would 
reply to remarks not addressed to her. Ordered morphia suspended; sina- 
pisms and G-ranville's lotion to back and chest; cold water to the head. At 
eight, satisfactory. Respiration normal, pulse 140. Myself or Dr. Jenkins 
with patient all night. 

17th, 2 o'clock A. M. Pulse has been 150 during the night; is now 
140; patient sleeps lightly. At 3 o'clock, gave morphia, three grs. At 
4 o'clock pulse 130; respiration seven; morphia suspended. 

8 A.M. Pulse 125; respiration better; diaphoresis still continues most 
profuse ; no pain ; bowels moved yesterday twice ; micturition free ; indifference 
towards child; face flushed and pinched somewhat; morphia resumed, gr. j 
every two hours. During this day pulse was 120. Patient slept; bowels and 
bladder evacuated freely. 

ISth, 6 o'clock A. M. Attendant asleep, room cold. Pulse 135. Patient 
restless; inquired whether that was her child crying. The morphia was 
continued at the same rate. 

10 o'clock P.M. Patient comfortable all day; pulse 120. Has mani- 
fested a good deal of anxiety about her child; asked me to send her some 
toast and tea from my table. Thus far her diet has been thin gruel. The 
morphia was continued. 

19th. Patient says she is first rate.'^ The bowels were moved three 
times yesterday, and as often to-day. 

20th. Patient continues to do well; bowels opened six times yesterday; 
stools pea-green and of the consistency of soup. The lochia returned in the 
evening. 

23cZ. Pulse 100. Patient has a bed-sore, but is doing well on a generous 
diet; cannot sleep without morphia. Milk begins to be secreted in small quan- 
tities. 

27th. Patient is well, though lacking strength, and some tissues destroyed 
by the bed-sore. The morphia is still required, though in diminishing 
doses. 

Jan. 1851. The secretion of milk has not been re-established fully, and the 
child has therefore been given to a wet-nurse. Otherwise, Mary B. seems to 
have quite recovered from her illness. 



Art. XII. — Cases of Delirium Tremens successfully treated hy the Administra- 
tion of Chloroform. By Stephen H. Pratt, M. D., of Baltimore. 

Case I. — May 7th, 1850, I was called to see E. B., labouring under deli- 
rium tremens. 

E. B. had, that day, been taken from the Infirmary, where he 



1852.] 



Pratt^ Cases of DeUrium Tremens. 



143 



had been for the last seven days under judicious treatment for the above-named 
disease. During this time (seven days) he had not slept any, as I had been, 
that morning, informed by the resident physician ; and his case was deemed 
almost hopeless. His friends became alarmed, and (very injudiciously, I 
thought) removed him, and placed him under my care. 

It was 1 o'clock, P. M., when I saw him. He was very feeble, and much 
exhausted by disease and protracted wakefulness. His pulse was feeble and 
frequent. There were subsultus, muttering, great incoherence, with cold and 
clammy extremities. 

Having been advised that he had been on a mixed opiate and stimulant 
treatment, at least a part of the time, and having had some success previously, 
in the use of chloroform, I determined to use it now. Accordingly, one drachm 
of chloroform, diluted with water, was exhibited. At 5 o'clock (P. M.), another 
drachm was administered; and at 9, still another, diluted as before. At 10, 
he fell asleep and slept till morning. At 8 (in the morning), he waked and 
drank some gruel, after which he soon fell asleep and slept till noon. 

He now waked with a good appetite, which he too freely indulged by par- 
taking of soup. However, he was quite comfortable during the afternoon, and 
slept well through the night. Next morning, he vomited two or three times 
freely. The emesis was not violent, and was easily controlled. From this 
time, paying strict attention to his diet, he rapidly convalesced. 

During this sickness no medicine was exhibited but chloroform (not even 
aperients), and this but three times. On the fifth day, the patient left the 
house to attend to his affairs, and was soon in health. 

Case 11. — Was called to see J. H., June 4th, 1851, labouring under deli- 
rium tremens. Put him upon a mixed opiate and stimulant treatment through 
the day, and exhibited opium in full doses through the night. This was con- 
tinued two days and nights, without benefit. Indeed, the patient grew worse. 
The third morning I put him upon: R. Spts. sulph. gstheris. comp., tinct. 
Valerianae, ana 5iss ; to take ^ii every two or three hours, intermediately giving 
tinct. opii. At 8 o'clock P. M., gave a large opiate. At 10 P. M., gave 
tinct. opii 5j- At 12, repeated the dose; and at 2, again repeated it. All 
this time the patient grew worsC; and became ^'furiously delirious," frighten- 
ing all the household. 

Three men were employed to prevent him from jumping out of the windows 
(several attempts at which he had made), or otherwise injuring himself. At 
times he was a match for them all. At length he grew weak, becoming more 
and more prostrated by his great exertions. The family became alarmed, and 
wished further advice. A consulting physician was called in. A hot stimu- 
lating pediluvia and an opio tartar emetic treatment were agreed upon. 

I suggested chloroform internally, which was not wholly objected to, though 
not preferred by the consulting physician. Accordingly the former was tried, 
but unfortunately without success, the patient rapidly growing worse. 

He was now beyond control, a raving maniac, a terror to all present. His 
pulse was very feeble and frequent; so frequent it could not be counted with 
the existing tremor. His tongue was dry; there were also muttering, sub- 
sultus, and perfect incoherence, with cold and clammy extremities. 

Under these circumstances, I determined to exhibit chloroform as a dernier 
resort. 

A teaspoonful nearly, diluted with water, was administered. After one 
hour, the following was given : R. Spts. sulph. setheris comp., tinct. Valeriana, 
aa f5ii; chloroform f3i (at a draught). 

(The compound spirit of sulphuric ether and tinct. valerian were added in 
order to obviate, if possible, the danger of fatal prostration.) Fifteen minutes 



144 



Morgan, Paronychia an Ejpidemic. 



[Jan. 



after its exhibition, the patient fell asleep, and slept soundly three and a half 
hours. Meantime, perspiration ceased; his extremities became warm; his 
pulse grew calmer, fuller, and firmer. He then awoke much refreshed and 
quite rational, and had a free, natural dejection. 

Three teaspoonfuls of the mixture, R. Hoff.^s anodyn. and tinct. Valeriana, 
with half a teaspoonful of chloroform, were then exhibited. After this, he 
washed his hands and face, and bathed himself generally. In one hour, I ex- 
hibited f5iv of the mixture, with fgi of chloroform, and persuaded him to lie 
down. In a few minutes, he was asleep, and slept comparatively soundly four 
hours, when he arose, went down stairs, and evacuated his bowels. In fifteen 
minutes he was again asleep, and slept three hours, when he waked and drank 
a tumbler of milk, took a dose of spts. sulph. ^theris comp. and tinct. Valeriana; 
fifteen minutes afterwards he was asleep again, and continued sleeping through 
the night, rising, meantime, but once. 

In the morning he rose, drank some milk and beef tea, and after evacuating 
his bowels again went to sleep. His pulse was now good ; extremities warm, 
glowing ; subsultus greatly diminished ; delirium almost entirely wanting. He 
slept till about noon, and tlaen waked still more tnmquil. During the afternoon, 
lie slept and waked alternately, and rested well the following [night. His 
sleep was not comatose. When awake, he was wide awake, cheerful and lively. 
A day or two passed thus as he rapidly convalesced. On the 9th, he was 
walking about the city a comparatively well man. He has continued well since. 

Such are the facts. From a furious delirium, with subsultus, perfect inco- 
herence, cold, clammy extremities, a feeble, fluttering, frequent pulse, costive- 
ness, &c., by the tranquillizing and peculiar (shall I say specific?) influence of 
chloroform he was rescued, in a little more than an hour, and thrown into a 
condition the most favourable possible ; from which, in a few days, he was 
restored to his usual health. No emesis, or irritation of the bowels, occurred. 
No cathartics were exhibited, yet gentle motions followed the administration 
of chloroform. 

The methodus medendi of this wonderful agent I will not here attempt to 
explain. Facts are of more importance than inferences, and if, by this contri- 
bution, I add one to the facts already recorded, I shall be satisfied. 

Baltimore, Aug. 1851. 



Art. XIII. — Paronycliia an Epidemic. By James E. Morgan, M. D., 
Demonstrator of Anatomy in National Medical College, Washington, D. C. 

Paronychia has, without doubt, existed in Washington this summer as 
an epidemic; and, as its prevalence in that form has not, to my knowledge, 
been noticed by any writer, I have thought that an account of it might not 
be uninteresting to the profession. Scarcely a day passes but that I am 
called upon to prescribe for several cases of this apparently trifling, but 
always painful, and sometimes fatal disease. 

It usually commences with a pain in the arm and forearm, which continues 
for two or three days with greater or less intensity, according to the severity 
of the case. These symptoms then suddenly cease, and the patient is seized 
with a soreness like the pricking of a needle^ or brier, in one or all the 



1852.] 



Morgan J ParonycJda an Epidemic. 



145 



fingers. This continueg to increase in severity; the fingers and hand become 
very much swollen, the pain is almost insupportable, and the patient is worn 
out with suffering, without being able to sleep or rest. Constitutional symp- 
toms at last supervene. I have seen fever, loss of appetite, debility, and 
spasmodic asthma, terminating in death, follow successively in a few days. 

Case. — James Sumby, coloured, a brickmaker, setat 32, large frame, in 
general enjoyment of good health, was taken on the 3d of July with a pain 
in the arm, followed by paronychia of the worst form. I was called to see 
him on the 8th, and found him with some fever, tongue dry and slightly 
coated, pulse nearly natural, his finger and hand much swollen, and suffering 
great pain. I made a free incision into his finger, from which a large quan- 
tity of blood and pus was discharged. Ordered a flaxseed meal poultice to 
be applied to the hand, and ten grains of Dover's powder to be taken at night. 
On the 9th, I was sent for in great haste, and found him sitting erect in a 
chair, with great difficulty in breathing, mucous rale, and inability to lie 
down or expectorate. The countenance was hippocratic and anxious ; pulse 
quick and scarcely perceptible; extremities cold, and the whole surface suf- 
fused with a clammy perspiration. These symptoms, in a milder form, had 
made their appearance in the preceding night. I ordered the following: 
R. Tr. valerian vol. ^ss; lac. ammoniac ^iss; lac. assafoet. ,^ij. M. A 
tablespoonful every two hours in a wineglass-full of strong brandy toddy. He 
continued to grow worse, and died that night. 

Autop?,}j twelve hours after death. Abdominal viscera healthy, and of nor- 
mal size; heart natural; the bronchia3 and air-cells of the lungs, which 
crepitated to the touch, were completely filled with a bloody, tenacious mucus. 
I regarded this as a case of spasmodic asthma, caused by the same pathological 
condition of the pneumogastric nerve which exists in the spinal nervous 
system in tetanus, its mediate cause being paronychia. 

It seems strange, at first thought, that paronychia should become epidemic ; 
but when we reflect that so little is known of the laws that govern the exist- 
ence and propagation of epidemics, and that many diseases belonging to this 
class, such as furuncles, carbuncles, erysipelas, &c., are sometimes epidemic, 
it ceases to create surprise. 

I regard paronychia as a furuncle, modified in its symptoms by the struc- 
ture of the seat of its attack. The violent pain is imputed by writers to the 
hard and unyielding nature of the skin on the finger; but I presume that 
most practitioners have seen the skin, in this disease, stretched as much as it 
was possible for the parts under it to require even in the most intense inflam- 
mation. Some other cause, therefore, must produce the pain. I attribute it 
to the large number of nervous fibres distributed to the ends of the fingers. 

Professor Weber has shown, in his experiments on the sensibility of dif- 
ferent parts of the skin, that the nervous fibres on the points of the fingers 
are one-third of a line apart ; while those on the back, neck, and nates (the 
usual seat of boils) vary from ten to thirty lines. Supposing pain to be in 
proportion to the number of sensory nervous fibres, the greater suffering in 
paronychia is readily understood. In other respects, whitlows differ from 
boils; and the fact of both prevailing at the same time, and even in the 
same person, seems to go far in proving their identity. 



146 



Hutchison; Case of Change of Complexion. 



Art. XIV. — A RemarJcable Case of Change of Complexion, with Loss of the 
Sense of Smell. By Joseph C. Hutchison, M. D,, of Marshall, Salmie 
County, Mo. 

The subject of this notice, a slave (Jo), the property of Mr. B., of this 
neighbourhood, ast. 45, was born in Ky., of black parents, and was himself 
perfectly black until twelve years of age. At that time a portion of skin an 
inch wide, encircling the cranium just within the edge of the hair, gradually 
changed to white ; also the hair occupying that locality. 

A white spot next appeared near the inner canthus of the left eye, and from 
this the white colour gradually extended over the face, trunk, and extremities, 
until it covered the entire surface. The complete change from black to white 
occupied about ten years, and but for his hair, which was crisped or woolly, 
no one would have supposed, at this time, that his progenitors had offered any 
of the characteristics of the negro, his skin presenting the healthy vascular 
appearance of a fair-complexioned European. When about twenty-two, dark 
copper-coloured or brown spots began to appear on the face and hands, being 
limited, as they are at present, to those portions of the surface exposed to light. 
Had rubeola and pertussis when black, and again after having changed to 
white. Eyes black. Cannot smell, having lost this sense about the time his 
sable hue began to disappear. Taste unaffected. 

With the exception of chronic rheumatism, pertussis, rubeola, and scarlatina, 
which latter appeared after the change of colour commenced, he has enjoyed 
uninterrupted good health. 

The history of the above case was obtained from the patient himself, and 
Mrs. B., a respectable and intelligent lady, in whose family he was born and 
raised. It offers two interesting physiological anomalies — the disappearance 
of the pigmentum nigrum, and the affection of the olfactory nerve, with total 
loss of smell. The occurrence of measles and hooping-cough a second time 
(after having changed his colour), although a singular coincidence, is not very 
unusual, similar cases having occurred to almost every practitioner. 

There has been some difference of opinion among physiologists respecting the 
colouring matter of the cutaneous envelope; but the most recent observers assert, 
that it is secreted by pigment cells scattered through the epidermis, the colour of 
their contents determining that of the skin. The change of colour, in the pre- 
sent instance, must therefore have been effected by absorption of the pigmentum 
nigrum ; and, probably, destruction of the cells secreting it, which were re- 
developed in spots, after ten years, on those portions of the skin exposed to 
light. This metamorphosis occurred during perfect health, without any appre- 
ciable cutaneous disease. 

The loss of smell; it was presumed, was attended with loss of taste ; and, 



1852.] 



Hutchison^ Case of Cliange of Conrplexion. 



147 



with tins expectation, I entered upon an examination wliicli resulted, as will be 
seen hereafter, very differently from what had been anticipated. 

The integrity of the branches of the fifth pair, being necessary to the proper 
performance of the functions of all the facial senses, to which they are distii- 
buted, were carefully examined. There was no dryness of the conjunctiva; com- 
mon sensibility, and motion of the globe of the eye and eyelids normal; also the 
movements of the iris. Hearing perfect, Sensation of all parts of the ear unaf- 
fected. The secretion from the Schneiderian membrane not obviously increased 
or diminished; action of the dilators and compressors unimpaired; common sen- 
sibility of the nose perfect, internally and externally. Ether, ammonia, &c., 
produce a pungent, burning sensation, but excite no odour; the one being dis- 
tinguished from the other only by its greater degree of pungency. Rancid 
olive oil, castor oil, alcohol, tinct. camphor, &c., produce no sensation whatever, 
and cannot be distinguished from water. No obstruction of the nerves. SnulF 
irritates the Schneiderian membrane so as to excite sneezing. Here the evi- 
dence is conclusive that neither the portia dura nor trigeminus is at fault; the 
latter presiding over common sensibility, and the former regulating the action 
of the dilators and compressors of the nose, b}^ which the air is drawn briskly 
towards the upper part of the nasal cavity, in which part alone the olfactory is 
distributed. . 

There is no inflammation or abrasion of the mucous membrane in any part 
of the buccal cavity; common sensation is everywhere perfect. Butter was 
, readily distinguished from lard, also molasses from honey, citric acid from alum 
and borax ; a piece of bacon was easily distinguished from a piece of turkey, 
of about the same density of fibre. Although blind-folded, he could, without 
hesitation, call the name of each substance as successively applied to the gusta- 
tive apparatus, with the exception of the citric acid, which he had never tasted 
before. 

A great diversity of opinion exists among physiologists with regard to the 
existence of a special nerve of taste. Carpenter and others are of opinion 
that all our knowledge of the flavour of sapid substances is derived through 
the smell ;" that is, that the sense of taste, properly so called, depends for its 
existence on the integrity of the sense of smell ; that they are identical, and 
the gustative impression received on the tongue by the lingual branch of the 
fifth pair and glosso-pharyngeal, is nothing more than a modification of the 
sense of touch. And a case recently reported by Dr. Kneeland, to the Boston 
Society for Medical Improvement, of an individual who had lost the sense of 
taste and smell, while the trigeminus was unalfected, leads him to the same 
conclusion. On the other hand, the physiological works of the day abound in 
facts familiar to every medical reader (which it is unnecessary to repeat here), 
proving the existence of a special nerve or nerves of taste; that the power of 



* See American Journal of Medical Sciences, January, 1851. 

No. XLY.— Jan, 1852. 11 



148 Hutchison^ Case of Change of Complexion. [Jan. 

\ 

receiving tactile impressions is distinct from that concerned in gustation; that, 
although the sense of taste may he rendered more perfect by the sense of smell, 
when an odorous substance is applied to the tongue they are nevertheless dis- 
tinct. 

In the present case, notwithstanding the patient was deprived of the sense 
of smell, we were unable to detect any imperfection in the sense of taste ; for 
he could readily distinguish the taste of substances of not widely different 
flavours, as well as of those that possess no odour, and which tasted very much 
alike ; and, although the tongue is endowed with a very delicate and accurate 
sense of touch, we do not think he could, by this alone, distinguish between 
substances of the same temperature, consistence, and form, possessing no irri- 
tating or pungent properties (as, for instance, butter and lard, molasses and 
honey). 

In conclusion, although the facts here presented have not squared with our 
preconceived views, we think they offer strong evidence in favour of the exist- 
ence of a nerve of taste, exercising its special function, distinct and independ- 
ent of smell or touch ; still, we do not wish to be understood as being com- 
mitted to this opinion. Jumping at hasty conclusions, derived from insuffi- 
cient data, is a prevalent error, and one which we desire to avoid. The ques- 
tion can only be settled by an accumulation of evidence and facts, such as we 
do not, at present, possess. 

May iiJi, 1851. 



1852.] 



149 



REVIEW. 

Art. XV. — 1. Physician and Patient; or, a Practical View of the Mutual 
Duties, Relations, and Interests of the Medical Profession and the Commu- 
nity. Bj WoETHiNGTON IIooKER, M. D. 12mo. pp. 453 : New York, 
1849. 

2. Deontologie Medicale, ou des Devoirs et des Droits des Medecins dans V Elat 
actuel d.e la Civilization. Par le Docteur Max. Simojst. 8vo. pp. 590. 
Paris, 1845. 

3. The Moral Aspects of Medical Life, consisting of the ^^AJcesios^' of Prof 
K. F. H. Marx. Translated from the German, with Biographical No- 
tices and Illustrative Remarks. Bj James Mackness^ M.I). 12mo. pp, 
348. London, 1846. 

4. On the Relations of the Physician to the Sick, to the Puhlic, and to his 
Colleagues. By the late Christopher William Hufeland^ M. D. 18mo. 
pp. 37. Oxford, 1846. 

5. Guide ou Instruction pour connaitre et choisir im 3Iedecin. Par le Dr, 
T. Franck. Traduction Frangaise, 12mo. pp. 108. Paris, 1846. 

6. Des Devoirs et des Droits des Mddecins. Par le Dr. H. Scoutetten. 
8vo. pp. 27. Metz, 1847. 

7. Des Devoirs des 3Iidecins. Par le Prof. Forget, de Strasbourg. BulL 
de Therapeutique, tome xxxviii. 

8. Code of Ethics of tlie American Medical Association, adopted May^ 
1847. 

It is a curious and interesting fact that, of tlie two secular learned profes- 
sions, whilst law is almost entirely destitute of an ethical literature, medicine 
has in all ages attracted the attention of moralists, and afforded them a prolific 
theme and innumerable occasions for discussing the duties and rights of phy- 
sicians. If argument drawn from other sources were lacking, this considera- 
tion alone would justify the claim which the medical profession makes to rank 
next in honour to the clerical. At man's entrance into the world, scarcely has 
the physician's duty been fulfilled before the priest assumes his function^ 
ministers to the bodily pains and to the souFs sorrows attend him on either 
side through life, and when he is about to die the one provides him with a 
soothing draught, that he may listen in peace to the consolations of the other. 

In remote antiquity, medicine found its cradle near the shrines of divinities, 
and within the gates of their very temples; the minister at the altar was also 
the healer of the sick. Whether it be considered that this union of functions 
was the natural consequence of the prevalent notion that disease was an evi- 
dence of the wrath of heaven ; and that its removal was most eficctually to be 
sought in propitiating the Divine vengeance, or whether it be considered that 
the priesthood were inspired by their calling with a sentiment of benevolence 
which prompted them to assuage the ills of mortality; and that, to enforce their 
prescriptions, they felt a religious sanction to be the most effectual means, cer- 
tain it is that the veneration accorded in all ages to physicians must have 
originated in the close alliance of their own with sacerdotal duties. Even when 
medicine became an independent art, it was frequently studied and practised 



150 



Review. 



[Jan. 



by the priesthood; and, during the middle ages of our own era, numerous ex- 
amples are to be met with of the union of priestly and medical functions. 
The ph3Tsician, like the priest^ is by the nature of his duty placed in a less 
direct and immediate relation with the artificial beings whom the usages of 
society have moulded into unnatural shapes, than with men in their real form 
and character. To his eye the blemishes and vices of the physical and often 
of the moral nature of his patient must be unveiled, and he is frequently 
obliged to become the depositary of secrets which involve life or honour^ and 
to act both as counsellor and judge in the court of conscience. 

The physician is, moreover, perpetually called upon to determine questions 
which involve not only the future soundness and happiness of his patients, but 
even their lives. He is, therefore, bound never to lose sight of his accounta- 
bility to law and conscience, for the rectitude of his conduct. Through this 
habitual circumspection, he grows accustomed to regard his relations to his 
fellow-men in a moral aspect. Many questions of practice have been debated 
by medical writers with great provision of learning and dialectic skill, and with 
an earnestness that proved of how weighty importance they held it to reach a 
just conclusion ; and if, in the present age, less prominence is given to such 
discussions, let us hope that a due sense of right and wrong has been so gene- 
rally drawn from other sources as to render them less necessary than formerly 
to thoroughly educated physicians. But, if the principles which should regu- 
late the intercourse between physicians, and between them and their patients, 
may be looked upon as almost settled, there never was a time when the pro- 
fession needed, so much as at present, to be informed of the decisions which 
have been reached, and of the grounds upon which they rest. Formerly, the 
length of time to which medical pupilage extended, the solid elementary in- 
struction which was insisted upon, the distinction which the diploma conferred, 
and various other causes, combined to make the young practitioner conscious of 
his dignity, and sedulous to preserve his honour unquestioned, and his con- 
science unsullied. But since, in so many directions, the teachers in the schools 
are ignorant, the pupils raw, the instruction scanty, and the diploma a false 
certificate, the medical profession is infested with a horde of persons who have 
no other conception of it than as a trade, and who are entirely ignorant of 
those precepts and principles which have become part of the moral nature of 
all who have received a liberal education, and undertake the study of medicine 
as at once the most noble and the most difficult of pursuits. 

For reasons such as these, treatises upon medical ethics deserve to be widely 
circulated and carefully studied. Every one will find in them counsels to guide 
him in his intercourse with his patients and professional brethren, and to pre- 
vent many of the heart-burnings, jealousies, and disappointments which beset 
the practitioner's path. He will also learn from some among them, how to 
appreciate the false systems which tempt the unwary to barter their inherit- 
ance of scientific wealth for momentary applause, and to cherish for the 
noblest and most humane of pursuits a reverent love, that never fails to make 
one honoured and esteemed, and that secures for him the priceless blessing of 
a conscience at peace with itself. 

Among the works named at the head of this article, we shall adopt that of 
Dr. Hooker as the chief guide to inquiry, as well on account of its intrinsic 
excellence, as because it is purely American. This latter circumstance has 
doubtless stamped upon it the thoroughly practical character which is its dis- 
tinguishing trait, and which has perhaps obtained for it the honour of being 
pirated,'' for the benefit of our brethren of Great Britain, who, no less than 
ourselves, possess a delicate sense of right and wrong, and are equally well 



1852.] 



Medical Ethics. 



151 



able to appreciate the clear and direct judgments wliich the author pro- 
nounces. 

In his preface^ Dr. Hooker remarks that 

" The quackerv which is practised among medical men is a much greater 
evil than that wliich is abroad in the community. I attack it, therefore, with 
unsparing hand When the rules of an honourable professional inter- 
course shall come to be properly understood and appreciated by the public, one 
of the great sources of quackery will be removed/^ 

How far it was prudent to expose the errors of physicians to the public may 
very reasonably be questioned. For ourselves^ we are altogether persuaded 
that such a course is most unwise, for it seems certain that nothing can tend 
more to impair the confidence of the public in the medical profession, than an 
acquaintance with the errors and crimes with which so many of its unworthy 
members are justly chargeable. II /aut laver son linge sale en famille is a 
wise saying, as all experience proves. The errors of good men and the 
crimes of knaves are never discriminated by the vulgar, who have a keen 
relish for detecting blemishes in all who are by position or knowledge superior 
to themselves. The innate proneness to quackery, moreover^ of many who 
would feel shocked at being classed amongst the vulgar, is encouraged by 
everything that palliates their folly by seeming to afford a reason for dis- 
trusting the power of medical science. By one of the commonest acts of 
false reasoning, they attribute to the whole profession the errors of its un- 
worthy members, and to the art of medicine the mischiefs which its counter- 
feits occasion. If it is quite impossible to prevent a certain number among 
physicians themselves from embracing false systems and acting the part of 
charlatans, much more certainly will it be so to rescue from quackery persons 
who have just enough knowledge to serve as a soil for presumption and con- 
ceit, and most of all when the subjects of these failings are flattered by being 
placed in the judgment-seat^ to hear and pronounce upon the follies and the 
faults of the profession they are at the same time importuned to respect. In 
this country, quackery is most prevalent in those regions precisely where in- 
telligence is most developed by education, and where the habit of judging 
without appeal on every question that can employ the intellect is nearly 
universal. The same is true of Europe, so far as it can be in countries where 
the governments have not yet got rid of that antiquated notion, that they are 
responsible for the character and attainments of those who are to have charge 
of the people's health. We cannot for a moment believe, therefore, that any 
good is to arise from an attempt to explain to the laity the grounds of our 
title to respect, and least of all when that attempt is coupled with an ex- 
posure of the defects and errors of which tlie 'proftssion may hejustlij accused. 
It seems proper to express here the dissent from our author's views embodied 
in the foregoing statements, in order to prevent the necessity of recurring too 
frequently to the subject, and also by way of qualification to the judgment 
we shall venture to propose in reference to several portions of his book. 

The general divisions of the work are four, of which the first relates to 
quackery, and comprises more than one-half of the entire treatise; the second 
considers the obligations of physicians to each other and to the public; 
another treats of the mental relations of disease; and the last contains an ex- 
tended view of the reciprocal duties of physicians and patients. The chapter 
upon uncertainty in medicine, which opens the work, is an attempt to 
present a view of the inherent difficulties of medical science. If duly weighed 
and understood, it would silence the presumptuous voices of laymen, which 
are so often heard in criticism upon the opinions and practice of physicians, 



152 



[Jan. 



and would not be an inappropriate lesson for some of our own brethren, who 
are fain to reduce all the actions and phenomena of the living organism under 
some ingenious electrical, chemical, or mechanical theory. The vis medica- 
trix nature, and that cognate principle by which diseases possess a definite 
character, course^ and tendency, together with the influences which most fre- 
quently modify the course and termination of diseases, are succinctly but 
clearly illustrated, and the conclusion is fairly sustained, that, if so many 
causes are at work perpetually to modify the course of disease, no ordinary 
skill is needed by him who aspires to conduct a patient safely to the termina- 
tion of a malady ; and consequently, that whoever ventures to assume the 
office of physician without a thorough preparation for its duties^ is guilty of 
unpardonable rashness. 

This survey of the difficulties of medical practice should lead, not as it so 
often does, to a belief that the issues of disease are uncontrollable by the phy- 
sician, but to the conviction that he ought to be endowed with the highest 
degree of knowledge and skill. 

" Medical skill/' says our author, " consists in appreciating the actual state 
of the patient in all respects, and then applying such remedies, and in such 
quantities and forms, as will do the greatest probable amount of good." 

This brief sentence, although apparently so simple, contains an epitome of 
the objects of medical science and art. The author criticizes, not without 
some justice, those physicians who confine their attention to local manifesta- 
tions of disease, instead of allowing their due weight to remote and constitu- 
tional symptoms. This error is not now so prevalent as it formerly was, 
when the pathological consensus of organs was overlooked, because the new 
methods of detecting local symptoms gave rise to such brilliant results as for 
a time to eclipse the fruits of earlier observation. An analogous error in 
therapeutics is also blamed, that, namely, of prescribing for the name of a 
disease, instead of following, as an immediate guide)* the condition which 
actually presents itself. This, also, is a fault which we take to be much less 
common than it was a few years since; for at that time many were erro- 
neously persuaded that the conditions of therapeutics could be reduced to a 
scientific expression like those of pathology. This delusive doctrine has less 
influence than formerly, and the most authoritative writers seem to be con- 
vinced that the highest science in therapeutics is a " rational empiricism.'^ 

The following chapter contains, under the title of " Popular Errors," a 
notice of some of the prevalent fancies of the vulgar in regard to disease. 
The prejudice in favour of heroic treatment, of specifics, &c., the notion that 
medicine is essentially curative, the pos^ hoc ergo propter hoc mode of reason- 
ing in therapeutics, the idea that disease is a palpable entity, which medicine 
is to exorcise like an evil spirit from the economy, &c., furnish themes for 
very sound and sensible commentaries upon popular errors. Still, it should 
not be forgotten, that these very notions which we blame or ridicule, had their 
origin in the medical profession itself ; each was, in its day, the epitome of 
some theory invented by ingenious philosophers, and afterwards cast forth as 
part of the rubbish of our science. At this moment the popular language of 
France, and to some extent even of our own country, deals in phrases about 

irritation," which were inoculated upon the parent stock by the disciples 
of Broussais. If the people give currency to terms which we now denounce 
as valueless or absurd, it ought not to be forgotten that the spurious coin is 
the issue of our own mint. How far it is prudent or proper to initiate 
the laity into these secrets of human weakness may well be doubted^ but we 



1852.] 



Medical Ethics. 



153 



cannot think them to blame for parading the cast-off finery of our own philo- 
sophers. 

Chapter IV. treats specifically of Quackery. The origin of its remedies in 
trivial or absurd sources is amusingly illustrated. The most prominent of 
them may be arranged under three heads, viz., evacuants, alteratives, and 
cures for incurable diseases. The first, by producing a decided and sudden 
impression on the system, must often produce a salutary change in chronic 
diseases of the digestive organs ; the second, including tonics, has evidently a 
large field in which they may do more or less good; and the last appeals to 
that desire for life which seldom abandons the sufferer even in the most des- 
perate extremity. Yet, even allowing to these various agents all, and even 
more than all the real efiicacy they possess, it is evident that their virtues 
would form a very flimsy basis for the reputation they enjoy. Secrecy is the 
most potent ingredient in them all; the moment their actual composition is 
known, their value is reduced to a very low point. Omne ignotum loro mog- 
nifico, is the device under which quackery of every sort obtains its largest 
conquests. Secrecy, which in such matters is itself imposture, also infallibly 
leads to falsehood of a more direct kind ; and he who does not scruple to keep 
secret the nature of a remedy which he alleges to be useful, will have no hesi- 
tation in fabricating proofs of its efhcacy. 

"One who had been an apothecary/' relates our author, " and who had sold 
large amounts of quack medicines, stated, that in one year he sold three thou- 
sand dollars worth of one medicine; that he had no satisfactory proof of its 
having cured a single case of disease; that he had obtained, however, many 
certificates of cure, but not one from any person who had paid for the medi- 
cine.-'^ 

Some persons of sordid views maintain, that discoverers of valuable medi- 
cines should be entitled to rights in them secured by letters patent ; and our 
author, admitting the principle of the claim, although he does not think it 
could often be sustained, proposes that such persons should receive a public 
reward for the free use of their inventions. We would go a step farther, and 
deny that any invention in therapeutics is susceptible of being patented, or 
in any manner made the subject of reward or price. Quinine alone excepted, 
we possess no specific remedy. The value of every medicine is not so much 
intrinsic, as dependent upon the time, quantity, combination, stage of disease, 
&c., in which the agent is administered. Hence, the medicine itself forms 
but one of the circumstances, the union of which renders it curative; and to 
set a high price upon it alone, is to disregard, perhaps, the very conditions 
which are most essential to its successful operation. 

In the sequel of this chapter, several ancient and modern forms of quackery 
are passed under review; such as animal magnetism, the system of Paracelsus, 
of St. John Long, of Dr. Perkins, &c., and many amusing anecdotes are given 
of the impudence of their promulgators, and the credulity of their unlucky 
dupes. 

"The essential materials of quackery," the author remarks, " have been the 
same in all ages, and its history would be only a description of the endless 
forms into which these materials have been moulded." 

That it should be more rife at the present day than it has yet been, is but 
a natural consequence of evident causes, and it needs no prophetic vision to 
foresee its future vast extension. If medicine were its only field, some hope 
might be entertained of its expulsion; but there is not a branch of human 
knowledge or action in which its dominion is not securely established. When 



154 



Review. 



[Jan. 



we, as physicians, wonder at the confidence reposed by so many thousands in 
pretenders to medical skill, does it never occur to us that we are equally prone 
to place confidence in quacks of a difi"erent kind; that all our education, and 
all our abhorrence of being judged by incompetent judges, do not prevent 
us from following errorists in religion, sciolists in science, pretenders in art, 
smatterers in literature, and deceivers in politics ? If, when knowledge was 
less diffused than at present, and the votaries of error, attracted by authority, 
blindly accepted what they were told to believe, the dupes had at least the 
merit of hearty attachment to their false guides; but in this age of boasted 
enlightenment, we have the more pitiable spectacle of a self-sufficient pride 
in ignorance scoffing at the lessons of experience and wisdom, and arrogantly 
claiming the right of every one to be a law unto himself.^' The pride 
which every one feels in being able to pursue his own calling intelligently, 
moves men to sit in judgment upon subjects which neither their talents nor 
their education fit theni for comprehending; and since the partial enlighten- 
ment which has developed this baneful fruit must constantly become further 
and further extended through all classes of society, there is every reason to 
apprehend that the vices we have now to deplore will become more and more 
developed through many succeeding generations. 

Chapters Y., VI., and YII. are occupied by an extended notice of three of 
the most popular impostures of the day, " Thompsonism.^^ " Homosopathy,^^ 
and the practice of "Natural Bonesetters/^ The first and last of these follies 
are of indigenous growth, and forcibly illustrate the love of being deceived 
which is characteristic of ignorant and self-sufficient people. The anecdotes 
which our author relates of them are amusiag and well told, and besides 
afiording many entertaining illustrations of the ease with which the grossest 
impostures may become popular, offer, we think, a valuable commentary on 
the opinion that we should commend our own art to general acceptance if we 
would but condescend to explain it to our patients. It is clear, from these 
chapters, that the confidence of the people in any false system of medicine 
grows entirely out of the promises which its promoters are bold enough to 
make, and bears not the slightest proportion to its intrinsic worth. As long 
as physicians shall esteem it disgraceful to lie, they must be content to have 
their patients filched from them by those who are passed masters in this bad 
art; but as honest men they have little cause to repine at the gains which, in 
every other pursuit, as well as in medicine, are the wages of iniquity. These 
remarks are not, as a whole, applicable to Homoeopathy, for of that illusory 
art we may in charity suppose that there are many conscientious professors, 
since the mischiefs it gives rise to are for the most part of a negative charac- 
ter. It does not kill its victims; it only lets them die. Dr. Hooker, as 
many other writers have done, demonstrates its nullity as a science; and as a 
profession, he calls attention to the shabby array of its members, to prove how 
small a hold it should have upon the respect of educated and intelligent men. 
On a survey of their ranks, he remarks : — 

"No superior order of talent would be found among them. There would be 
none who are distinguished for true research; none who have made any 
respectable additions to the literature of medicine or to its store of experience ; 
and none who had ever had any commanding influence.'' 

Of this subject of Homoeopathy, we are of opinion that enough has been 
written; in a work like the one before us, it is true that a critical history of 
its absurdities finds an appropriate place, but we cannot persuade ourselves 
that it is worth the ammunition of reason, and sarcasm, and denunciation, 
which has been expended upon its flimsy structure. Asa system, it is almost 



1852.] 



Medical Etltics. 



155 



effete in tlie land of its birtli, and wo should pcrbaps do well not to warm it 
into life at tlie fire of controversy. 

In Chapter VllL; on Good and Bad Practice," our author treats of a diffi- 
cult subject. Since no two physicians, no matter how nearly alike in cha- 
racter, knowledge, and skill, can be found to agree perfectly in regard to the 
treatment of any disease, it is evident that the laity have a plausible reason 
for presuming that the art of therapeutics is wholly conjectural. Some years 
ago, for example, there were two parties amongst the medical men of New 
England, of which the one was led by Dr. Gtallup, and the other by Dr. 
TuLLY. The former denounced the treatment of the prevalent diseases by 
stimulants as incendiary; and their opponents, on the other hand, branded 
depleting remedies as murderous, declaring that " the lancet is a weapon 
which annually slays more than the sword." Both could not be wholly in 
the right; and if " it were easy, by looking at results to decide in all cases 
what is good, and what is bad practice, it is evident that such diametrically 
opposite modes of treatment could not be in vogue at the same time." If 
such complete dissidence in opinion amongst well-informed and equally skilful 
and equally honest physicians be consistent with the successful treatment of 
disease, we cannot wonder that the public should see no reason in their 
mutual antagonism for rejecting the several opposing systems which challenge 
their confidence. 

" To say nothing of minor claimants, there is Thompsonism, almost parboiling 
its patients with steam, and shaking them to shreds with lobelia, and burning 
them up with cayenne ; and Hydropathy, that wraps up its devotees in the cold, 
wet blanket ; and then gentle, sweet, refined, sublimated Homceopathy, that starts 
with horror at the very idea of such harsh means, and professes to neutralize 
all disease with little else than the mere shadow of medicine. Each one of 
these systems, so opposite to each other, asserts its claim to be the only true 
system of medicine, and bases this claim upon the success which attends it.'' 

If these and similar modes of practice are really erroneous, what infallible 
marks, it may be asked, can be resorted to for distinguishing between the true 
and false in medicine? Should we fail to assign any such, it would seem that 
we are unduly harsh in the judgments we pronounce upon those who prac- 
tice and upon those who encourage such systems. But the question is not to 
be thus categorically proposed or answered. As no medicinal agent is in- 
trinsically good or bad, but acquires either quality from its relation to the 
circumstances under which it is administered, so also the agents which are 
employed by the sectaries of the different systems alluded to, and of all others 
that have ever existed, are not in themselves either mischievous or useful; 
they acquire one or the other character solely from being appropriate or the 
reverse. The agents of Thompsonism are capable of producing changes in 
the economy which, under certain conditions, may restore health; cold 
water is a valuable remedial agent, and was employed as such long before 
the Silesian peasant began his murderous career; placebos have always been 
an important division of the Materia Medica, although it was reserved for a 
G-erman dreamer to fabricate a system for administering them. It is not the 
agents that we condemn, for their merit and their demerit are altogether subor- 
dinated to the mode of their employment; but the systems to which they adhere, 
or upon which, like fungi, they receive an accidental nutriment, these are 
the object of just censure and ridicule, for they set themselves up to be the 
exclusive objects of our respect, and insult common sense no less than they 
outrage common decency, by calling upon us to discard the accumulated 
lessons of wisdom and experience. Thoroughly we agree with Professor 



156 



Review. 



[Jan. 



Bartlett, in regarding the exclusive hypotheses which have been broached by 
distinguished men in the medical profession, as not one whit more respectable 
than the vagaries of professed quack-salvers; and the treatment of disease 
prescribed by them, as deductions from their hypotheses, as being quite upon 
an equality with the incendiary medication of Thompson, and the infinitesimal 
nonsense of Hahnemann. 

" The truth is," says Dr. Hooker, " that no exclusive system of practice can 
be said to be a good system ; for it is impossible that it should suit all the 
varying states presented by disease." 

That any system of quackery, or any system deduced from a pathological 
hypothesis, should succeed in curing a sufficient number of cases to keep it 
alive for a longer or shorter space of time, depends upon two causes ; the first 
of which is that, out of the whole number of cases to which it is applied, it 
acts favourably upon a certain number. If it be a sedative plan, it can hardly 
fail to do good in many of that large class of inflammatory diseases; if it be 
an excitant method, not a few cases of sthenic affections in the forming stage, 
and not a few cases of a dynamic t^^pe, will demonstrate its utility; finally, if 
the disease, of whatever type, attack a constitution capable of successfully re- 
sisting and at last overcoming its downward pressure, it offers an appropriate 
field for the triumph of infinitesimal doses. 

"In a great majority of cases of sickness which fall under the care of a phy- 
sician, the vis medicatrix naturce is competent to effect a cure if they are left to 
themselves ; and in most of them it will do so, even though a positively bad 
treatment may be pursued." 

The occasional and accidental good to which charlatanism may lay claim, 
is certainly not to be weighed against the enormous mischiefs it is guilty of 
producing at every step of its progress. For the former, even, is not good 
unalloyed; if it does not prevent but sometimes even assists the recovery of 
the sick, its cures are seldom such as rational treatment would have performed 
under similar circumstances. The cito, tuld, et Jiicunde, of legitimate thera- 
peutics is not its motto; it doles out its nostrums, gripes its wages, and leaves 
the event to chance. In that " accurate adjustment of remedial means to 
the ends to be accomplished," which distinguishes the skilful ph3^sician, the 
cjuack is altogether wanting, and hence it happens that so many of those 
who have paid tribute to him are compelled, at last, to resort to physicians, 
to have the consequences of his ignorance or neglect repaired. 

Our author thus sums up the points in which the practice of the really 
skilful physician differs in its results from that of the injudicious practitioner 
and the quack : — 

" 1. He has a less number of fatal cases, in proportion to the whole number 
that come under treatment. 

" 2. He has a less number of bad cases, because he avoids converting light 
cases into grave ones, and succeeds in many cases in arresting disease in its 
very commencement. 

"3. His patients have commonly a shorter sickness. 

"4. They are in a better condition after they have recovered, less apt to 
have bad results left behind, and less liable to disease in future. 

"5. He has a less number of patients, and a smaller amount of sickness, 
in the same number of families." 

To appreciate these differences, it is necessary that a sufficient number of 
facts be brought in evidence, and that we should be capable of observing 
them correctly. But, as the author observes, it is almost impossible, for a 
layman at least, to judge of practice by the results which fall within the com- 



1852.] 



Medical Elides. 



157 



pass of his observation; the only logical method, therefore, of persuading the 
'intelligent patron of quackery to desist from his mischievous conduct, is to 
convince him that he is utterly incompetent to form an opinion upon a 
subject which physicians alone can understand, and which to them, even, 
is surrounded by innumerable difficulties. But we suspect that the patrons 
of charlatanism are not to be driven from their delightful task of pro- 
pagating error and fostering mischief by these or indeed any arguments. If 
they are silly enough, at first, to embrace any one of the popular delusions, 
they will unquestionably be vain enough to cling with insuperable tenacity 
to it, and all the more strongly the greater the effort which is made to detach 
them from their hold. Pride in error is infinitely more obstinate than at- 
tachment to truth. 

In a subsequent chapter (Chap. X.), our author attempts to answer the 
question, ^' PIow shall the community judge of physicians?" If, as had been 
previously shown, the community is entirely incompetent to form a just judg- 
ment of medical men and their art, upon any scientific ground whatever, 
what guide shall they follow in making choice of the physician who is to be 
entrusted with their own and their families' health and lives ? Surely, they 
ought to have some good reason for so important an act. Every one knows 
how the choice is usually made, and that no stronger motive than personal 
partiality determines it, even in the absence of any proclivity whatever 
towards irregular systems. But where there is an itching after novelty, com- 
mon rumour, that fertile mother of the whole spawn of quackeries, vouches 
for the skill of the charlatan, and the profundity of his doctrine. It would be 
an amusing, were it not a pitiable sight, to see many persons of intelligence 
and education imagine that, when they call in a quack, they are actually 
making proof of independence, and superiority to vulgar prejudice, whereas, if 
they would but examine the real links in the chain of influences which has 
led them to this result, they would find that, so far from acting independent- 
ly, they have in reality followed the example, not of the wise, not of the good, 
not of the skilled, but of the ignorant and self-willed multitude, or obeyed 
the voice of their own worst passions, their vanity and pride. " The worst of 
all ignorance,'^ said Socrates, ^' is the conceit of knowing what you do not 
really know.'' What, then, with the wise in their own conceit, who reject 
all sound advice upon the subject, the ignorant, who are quite unable to form 
an opinion, the enthusiasts who are joined to their idols, and those who 
walk in the steps of their forefathers as the only right way, it is plain that 
the number who are likely to profit by the advice conveyed in this chapter, 
must be extremely small. Nevertheless, since in this as in everything else, 
there is a right and a wrong, it is not amiss that the few who doubt, and yet 
desire to know, should be furnished with a safe guide towards a decision. 

The best work on popular medicine," says Joseph Frank, is that which 
teaches how to choose a good physician." Dr. Hooker presents the greatest 
number of grounds, and the best considered, upon which this choice should 
be made, and we shall therefore follow him in the further prosecution of this 
subject. In the first place, the evidence of his having received a thorough 
education should be examined as the primary qualification of a physician. 
" But education in the science of medicine is practically despised by quite a 
large portion of the community :" to use the popular formula, the fact that 
the physician is successful in treating disease is worth vastly more than a piece 
of parchment." Indeed, we are persuaded that the half-educated or the 
wholly ignorant man, who has boldness enough to make high pretensions, and 
adroitness enough to palm off natural effects as the result of his skill alone, 



158 



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[Jan. 



is almost sure to inspire more confidence than the conscientious, and therefore 
circumspect physician. His very ignorance is a charm ; he is supposed, by 
the intuition of his genius, to discover more than the learned practitioner 
can do by study and observation; not a few, even, of the genteel vulgar 
imagine that he has a "gift'^ which makes him quite independent of the ordi- 
nary processes for acquiring skill. Unfortunately, this error is fostered by an 
equally gross one in the profession itself. There are so many physicians of 
little talent and less learning, and who openly affect -to disdain both as com- 
pared with tact and experience, that we ought not to wonder at the large 
number beyond our limits who despise what our own brethren undervalue. 
How large a number, too, of those who annually enter the profession, whose 
general and literary education is absolutely null, and who have been made 
doctors of medicine after a period, we will not say of study, but of attendance 
upon lectures, which is only sufficient to reveal the impossibility of their ever 
being fit to treat disease ! So long as a large proportion of medical men are 
wholly uneducated, or only instructed enough to make them dangerous to the 
sick, we have no right to complain that the public prefers employing professed 
charlatans, rather than those who, with the title of Doctor, have none of the 
accomplishments which belong to so honourable a name. It is to our disgrace 
as a body that we do not insist upon a higher standard of professional and 
general education than is now exacted. It cannot be expected that men who 
have never formed habits of study in early life, who know little or nothing of 
the art of observation or the science of reasoning, should become reallj'- ac- 
complished j)hysicians. That they may have a reputation for sagacity and 
success among their patients, and even amongst a certain class of their bre- 
thren, is very probable; but that they should become really consummate prac- 
titioners, is next to impossible. Ilhazes, says Dr. Forget, although he 
belonged to the empirical school, declared that " he would have more confi- 
dence in a physician who had never seen a patient than in one who was igno- 
rant of medical literature.'^ Hecquet was wont to remark, 11 y en a qui 
voient heaucoup de malades, mais je vols peiit-etre plus de maladies." Eut 
the public fancies that the seeing many patients is experience; it cannot 
understand that he who sees them with his natural eyes only may be stone 
bhnd to everything in them which it is the province of the educated phy- 
sician to perceive. To bring the public, then, to a sense of this error, it is 
necessary that they should have a degree of intelligence and special instruc- 
tion which they cannot be expected to possess, and least of all in a country 
where every avocation is open to men of the lowest capacity and attainments. 
For if they who should illustrate their profession are themselves ignorant of 
its scope and excellence, how is it to be expected that others will comprehend 
its nobleness and its extent, or appreciate its value to mankind ? 

A much safer guide than that which has been considered, for discovering 
the merit of a physician, is to be found in the unbiassed opinion of his 
medical brethren." This test, it is true, cannot readily be applied by one 
who is about to choose a medical adviser. He can hardly discover what the 
opinion of the profession is, for if, as our author suggests, some of the brethren 
are unjust through prejudice, many more will run to the opposite extreme, 
and, to avoid the suspicion of injustice, palliate the faults and perhaps exag- 
gerate the abilities of their rival brother. Besides, it is not to be concealed, 
that professional excellence is not the only title to the confidence of the public, 
which a physician should possess. He ought also to be richly furnished with 
those humane sympathies which will secure to him the love and confidence 
of the families which employ him ; indeed, he will have perpetual occasion to 



1852.] 



Medical Elides. 



159 



exhibit tliera, and comparatively very seldom to display a high degree of pro- 
fessional skill. The estimate of his brethren^ therefore, founded upon the 
degree of his proficiency in medical science, is not always a reliable guide to 
those who seek something more in their physician than dexterity in the diag- 
nosis, and skill in the treatment of disease. 

Our author next points out certain means of ascertaining whether a phy> 
sician possesses the mental qualities which are essential to his being a skilful 
practitioner. His advice to the inquirer is embodied in the following rule: 
" Let him observe the mental qualities of the physician, as they are exhibited 
in regard to any subject with which he is himself familiar in common with 
physicians.'' If the physician is observed to be credulous about politics, reli- 
gion, or the occurrences of the day, he may be inferred to be inaccurate in 
his observations of disease; if he is a skeptic, his treatment of disease will 
be marked by hesitation.'" If he forms his conclusions hastily, he is unfit to 
manage serious and complicated cases; if he is unduly slow in making up 
his m.ind upon ordinary occurrences, and obstinately fixed in the opinions he 
has formed, he will not be ready to adopt those changes of treatment which 
the course of disease recjuires. To determine whether he is a good observer, 
his mode of examining patients will not suffice, for the layman cannot judge 
of the necessity or appropriateness of his queries, and, according to Dr. 
Hooker, " minuteness of examination is in fact one of the most common 
tricks of the trade." We here remark, eri ijassant, that it is a thousand pities 
the " trick" were not more common ; it is rather too laborious a one to suit 
the fancy of a charlatan. These criteria, then, failing from the difficulty in 
applying them, the patient is advised to see how the physician observes in 
regard to some subject with which he himself is acquainted;'' to endeavour, 
according to the advice of Cabanis, " to estimate the scope of the physician's 
intellect, the precision and honesty of his judgment in matters foreign to 
medicine, but with which the inquirer is familiar." The character of his 
measures in the treatment of disease may be inferred, according to our author, 
by observing what measures he proposes when acting, not in the capacity of 
a physician, but in that of a citizen, a neighbour, a member of an association, 
and what reasons he gives for these measures." 

We are disposed to admit the value of these rules in many cases, but by 
no means in all. They may be true in their positive application, at least 
generally, but negatively they are useless to guide inquirers. If a physician 
really possesses a logical mind, is cautious, yet decided, of precise and upright 
judgment, a good citizen, neighbour, and parent, undoubtedly the union of 
all these qualities renders him most probably a skilful and prudent practi- 
tioner. But the negative of the proposition is not equally certain. There 
are not a few physicians who possess profound knowledge and consummate 
skill, and who are nevertheless mere children in non-professional matters; who 
are totally ignorant of, because they are careless of, the ways of the world in 
various matters which absorb the interest of the community; who even are 
so alien to the common sentiment, as actually to think infinitely of their 
patients' lives, and not at all of their patients' fees — who yet, we say, hold 
the first rank in the love of the community, and the honour of their brethren. 
According to our author's rule, these persons would, we suspect, run great 
risk of being pronounced unworthy of the confidence of the public. We do 
not wish to exaggerate the importance of this objection to Dr. Hooker's rule, 
but we are bound to produce it; else some of the best, and purest, and most 
skilful men might be judged unworthy of the confidence which they pre-emi- 
nently deserve. 



160 



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[Jan. 



The chapter entitled ^' Theory and Observation'^ is one of the moot inte- 
resting and valuable in the work before us^ and deserves to be carefully 
studied by all who think it an easy matter to distinguish truth from error in 
medicine, or indeed in any other department of knowledge. 

"All real knowledge/^ says Dr. Hooker, "is based on observation." . . . . 
" Not a single grain, has ever been added to its store, in all the ages of the 
world, through the instrumentality of theory alone." — " Facts are of two kinds, 
particular and general. General facts are discovered by a careful observation 
of a great number of particular facts." 

This is the true philosophical basis of medicine, and of every other natural 
science. Observation first, and then the generalization of the results of ob- 
servation in the form of a theory. Our author has not, we apprehend, made 
a proper distinction between theory and hypothesis. He employs these terms 
as synonymous, as in fact they are popularly employed in opposition to posi- 
tive knowledge. They are not, however, synonymous, but of opposite signi- 
fications. Professor Olmstead has accurately defined them in the following 
terms : A theory is founded on inferences drawn from principles which 
have been established on independent evidence ; an lii/potliesis is a proposition 
assumed to account for certain phenomena, and has no other evidence of its 
truth than that it affords a satisfactory explanation of those phenomena." — 
(^Wehster's Diet., Theory.) So that, when our author tells us that "the 
laws of the circulation of the blood, as discovered by Harvey, are sometimes 
erroneously spoken of as his theory of the circulation," his criticism is not 
founded upon a correct appreciation of the word theory. 

It is true, however, in point of fact, that most of what are called medical 
theories, are assumed explanations of morbid phenomena, that is to say, 
hypotheses, and not formulae constructed by an induction from facts ] or, if 
originally based on direct observation, they have grown into their actual form 
by the superaddition of gratuitous and artificial parts. We can, therefore, 
speak of theories and hypotheses as synonymous, without grossly violating 
historical accuracy, and, so doing, can heartily subscribe to the following re- 
marks : — 

" An overweening attachment to theories has been a very great obstacle to 
the advancement of medicine as a science. It has turned the medical mind 
away from the legitimate pathway of discovery, and the strict observation of 
facts has been neglected in the contemplation of mere fancies. 

" It is true of medicine, as it is of every other science, that every advance 
which has been made has been efi'ected by observation, and by observation 
alone. It is the good observer, and not the mere ingenious theorizer, who has 
made these advances. And if the theorizer has added anything to the store of 
knowledge, it is only when he has come down from his airy flight of fancy to 
the drudgery of humble common observation. He has for the time forgotten 
his favourite theory, and has subjected hypothesis to its proper subserviency 
to observation, in suggesting the points to which that observation may be 
directed. It is in this way, and in this alone, that many of the authors of theo- 
ries, escaping, occasionally, from the domination of a theorizing spirit, have 
added rich treasures to the storehouse of medical science. Even before the 
discovery of the circulation of the blood, though medical theories necessarily 
contained many absurdities, yet many of their advocates were acute and accu- 
rate observers ; and their fiicts are valuable, though the theories which they 
framed to account for these facts may appear to us even ridiculous." 

Without for a moment denying that theories, in the strict sense of the 
term, and even hypotheses, may have been useful in medicine, their advan- 
tages have been infinitely outweighed by the mischiefs which they have occa- 



1852.] 



Medical Ethics. 



161 



sioned. Of tliese, the most portentous is the commonly received notion that 
the treatment of disease is founded upon a knowledge of its nature, and not 
upon the observed and recorded phenomena which medicinal agents give rise 
to when they are brought into relation with the sick. Comte, the celebrated 
author of La PluJmophie Positive, has declared, in a general formula, that 
Sciences are not the bases of arts,'' and an ingenious writer of our own 
country has maintained that the art of medicine has been but little, if at all 
advanced by the greatest of anatomical discoveries, the circulation of the 
blood. We may add that the curative powers of bark, of mercury, indeed 
of all medicines, have not the slightest possible relation to any theory which 
has been contrived to explain their efficacy. Nevertheless, 

" Restricted to its proper sphere, theory is of essential service in extending 

the boundaries of science. It often suggests the line of discovery 

The abuse of theory consists in the obliteration of the distinction between what 
is known and what is merely supposed. So long as this distinction is carefully 
preserved, no harm is done by theory." 

But, unfortunately, men are so prone to be tempted by the reputation 
which they may gain by ingenious speculations, so fond of the intellectual 
exercise itself, and so easily induced to eke out the incomplete responses of 
the oracle of nature by inventions of their own, that the distinction is seldom 
preserved, and our literature is encumbered with works in which it is im230s- 
sible to distinguish between hj'pothesis and fact. 

Among the influences which are adverse to shill in the observer," are 
noted a faulty mode of reviewing the cases which have come under his care, 
with reference especially to his influence on the successful or untoward results 
of treatment j the disposition to form conclusions from a limited number of 
facts, or from a partial view of them; a propensity to liouhy -riding, especially 
on new hobbies, pathological and therapeutical; an easy credulity, and, finally, 
skepticism. On all these subjects our author's remarks are sound and appro- 
priate, and aptly illustrated. We select the following passages, as examples 
of the manner in which these topics are treated. 

"One of the prominent faults of the medical profession in the nineteenth 
century is that it is as a body too fond of new things and too much disposed to 
receive them upon doubtful evidence. There is a great disposition to hail every 
new remedy with enthusiasm. The annals of medicine are, therefore, bur- 
dened with false statements in regard to the eflfects of remedies. Though the 
public think that there have been of late many discoveries of new medicines of 
great value, there really have been but few. There have been many improve- 
ments in the forms of medicines. I mention as examples, quinine and mor- 
phine, the active principles of bark and opium. Bur there have been but feAV 

absolutely new medicines introduced which are of any importance And 

it may be remarked that physicians, who try all the ncAV remedies recom- 
mended from time to time in medical journals, do not add so much to their 
stock of available experience, as those who are more cautious, and less ready 
to adopt everything which is new." 

Of skepticism, it is remarked that 

" It not only narrows the limits of knowledge, but actually leads to positive 
error. The skeptic, in his demand for stern fixed facts, rejects some facts which 
are established by evidence that is sufficient to satisfy any mind possessed of 
candour and common sense; and the rejection of a well-proved fact, being itself 
an error, must necessarily lead to other errors. The skeptic, too, with all his 
doubting, is always, to some extent, and on some points, a credulous man. As 
he doubts on some points against clear evidence, so he will assuredly believe 
on others against evidence just as clear. His beliefs are no more worthy of 



162 



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[Jan. 



confidence than liis doubts. The skeptic is, therefore, disqualified by his skep- 
ticism for accurate observation.'^ 

Concerning the influence of a theoretical or of a practical turn of mind 
upon the usefulness of a physician^ the following sound doctrine is taught: — 

" In medicine, as well as in every other science, but little mental effort is 
required to frame theories. All the hard work Which is done, the work by 
which all knowledge is accumulated, is the work of observation. It therefore 
needs a higher order of mind to ascertain facts and their relationships, than it 
does to theorize. 'Any man,' says Pott, ' may give an opinion, but it is not 
every mind that is qualified to coilect and arrange important facts.' " 

"It is important that the physician should have at the outset good habits of 
observation. If he does, every daj^'s experience will add to his store of facts, 
and, at the same time, relieve it from some of the chafF of error which has been 
brought in unawares. Re icill be all the time becoming a better practitioner. But, 
on the other hand, if he start with a loose habit of observation, experience will 
be to him a source of error. He will have no clear store of facts, but he will 
garner in a strange mixture of facts, and suppositions, and errors ; and every 
day's experience will add to the difliculty of separating the good grain from 
the mass of refuse with which it is mingled. Re will be all the time becoming 
a poorer practitioner. 

" The idea, then, that experience will, at any rate, confer knowledge is a false 
idea. It is not true that the old physician, as a matter of course, knows more 
than he did when he was young. If he has observed well, he does know more ; 
but if he has not observed well, he not only does not know more, but he knows 
less." 

We quote two or three striking passages upon the relation of medical theo- 
ries to therapeutics : — 

"It is easier to adopt a theory with a corresponding system of remedial 
means, or even to originate one, than it is to encounter the labour of strict 
daily observation at the bedside of the sick." . . . . " Every prominent theory 
can be shown to be unsubstantiated by facts, and is, therefore, valueless. Every 
system of practice can be shown to exclude many facts of a valuable character. 
All these systems, therefore, should be discarded.'' .... "The modus operandi 
of many remedies is wholly unknown, and the knowledge we have of it in any 
case is more or less imperfect. And, after all, though it may gratify curiosity 
to know hoic a medicine cures disease, it is comparatively a matter of little im- 
portance. The fact that it does so is the material fact." 

It is not uncommon for those who adopt this view of therapeutics to be 
sneered at as " empirical," and behind the age which has provided a theory 
for the modus operandi of almost every class of medicines; they are twitted 
with having no scientific principlcvS; and as degrading the profession instead 
of elevating it to its proper rank. When it shall be shown that we are not 
nourished by the food which we consume, because we are ignorant of the in- 
genious hypotheses of Liebig, and Muller, and Mialhe, we may be ready to admit 
tliat a therapeutical theory contributes to success in the treatment of disease. 
Till then we take leave to doubt that any other knowledge in therapeutics is 
necessary than the precise circuimtances in which medicinal agents have proved 
to be curative. But this knowledge, be it well understood, is infinitely more 
difficult to gain, by reason of its vast extent and complexity, than a familiarity 
with the various ingenious hypotheses which amuse philosophers and delude 
practitioners. Far be it from us to cast discredit upon the labours of the dis- 
tinguished men who have devoted themselves so zealously to unravelling the 
mysterious processes by which medicinal agents become remedies for disease; 
they are worthy to be had in honour for the ingenuity of their experiments, 
the profundity of their speculations, and the striking discoveries made by 



1852.] 



Medical Etliics. 



them of the manner in which medicines enter the' economy, the changes which 
they undergo therein, and which they in their turn produce upon the elements 
of the organism. This knowledge is most precious, but it is a diflPerent know- 
ledge from that we are in search of, to wit, how they cure disease. Between the 
demonstrable action of a remedy and the visible pathological change which is 
the index of disease, there is, it seems to us, a great gulf fixed, which man 
has not yet bridged, and which seems to be in its nature impassable. 

In Chapter XI. are considered "the means of removing quackery." Our 
author differs from those (of whom we confess ourselves one) who think that 
there must always be a class of persons addicted to quackery. Of those who, 
" from the very character of their minds," have this propensity, he, too, has 
little hope, but he thinks "among those who are intelligent and judicious on 
other subjects, and yet are deceived and captivated with the false pretensions 
of empiricism," there are many who may still be rescued from their delusion. 
Upon this point we dissent from him completely. We should have far greater 
hope of the comparatively ignorant classes, who are more accessible to truth, 
because they are not so completely equipped in the armour of self-sufficiency, 
which the learned, and polite, and intellectual quack-mongers wear cap-a-pie. 
In countries where the people do not enjoy the inestimable blessing of a news- 
paper, and are, of course, debarred from the information upon medical 
subjects in which these veracious oracles abound, quackery scarcely exists in 
its most mischievous form. The peasantry, and others even, may listen to 
wandering charlatans, or confide in some domestic oracle, but they seldom 
fail to show respect to the physician, or to appeal to him in case of need. 
They may commit follies, but they are not vain of their foolishness. It was 
reserved for countries in which popular freedom and popular education are, at 
the same time, carried to the highest point, to produce examples of vainglo- 
rious ignorance scoffing at wisdom and experience, and setting itself in the 
judgment-seat to pronounce sentence upon what it cannot comprehend. In- 
stead of diminishing, this evil must, by its very nature, continue to increase. 
No one can, of course, be found to suggest that liberty of opinion should be 
curtailed. But liberty of opinion includes, of necessity, the formation and 
adoption of false opinions upon religion, politics, art, science, everything; 
because an immense proportion of the whole number of citizens must of like 
necessity be ignorant. If the political system they live under makes them 
equal to their neighbours, the changes of fortune give them a social equality, 
and they endeavour to conceal their ignorance by affecting to have opinions 
and to pass judgment upon what they cannot possibly comprehend. As 
Frank remarks, nature abhors a vacuum ; and, therefore, the empty heads 
of these folks are filled, in default of truth and sense, with a swarm of absurd 
and incongruous follies. But these persons are vulgar patrons of quackery ; 
if they form to themselves any definite idea why they thus make sport for wiser 
men to laugh at, they imagine, probably, that it is far more distingue to be- 
come the gulls of any absurdity, than to walk quietly and unobtrusively in 
the paths of common sense. 

But the most mischievous promoters of error in regard to medicine, the 
most industrious co-operators with the unprincipled gang that infests the com- 
munity, periling and even destroying the lives of the unfortunate persons 
who confide in them, are in reality to be found in the most educated classes, 
among those who, according to our author, "are intelligent and judicious on 
other subjects," or, at least, are so in the ordinary affiiirs of life. They may 
be acute lawyers, eloquent preachers, sagacious merchants; but one thing they 
No. XLV.— Jan., 1852. 12 



164 



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[Jan, 



assuredly are not, men of well-balanced minds. In hardly any instance is a 
person of this class to be found promoting quackery in medicine without 
fostering it, at the same time, in some other department or pursuit; he will 
assuredly be seen fighting under the banner of some new-fangled religion; 
will be noted for his zeal in what is called " Reform," which too often means the 
destruction of a substantial reality and the substitution in its place of some 
fantastical chimera; or will be ardently industrious in some of those philan- 
thropic associations of which each one promises to be the salvation of man- 
kind, though it may bring present and direct ruin upon thousands, &c. &c. 
It were in vain to include in a few sentences a catalogue of the absurd doc- 
trines, wild schemes, and mischievous practices which are invented and pro- 
moted, and even believed in, by these superior persons. They are self-reliant 
people; they imagine that they have a lever with which they can move the 
world even without the fulcrum which Archimedes postulated; the virtues of 
faith, contentment, and humility, find no resting-place in their tumultuous 
bosoms; they expect to usher in a millennium of peace by teaching that every 
man shall be *'a law unto himself," and thus setting every man's hand against 
his brother. Such are the persons of whom our author has more hope than 
of the ignorant crowd, with whom addiction to error is a matter of sentiment 
only, and not of reasoning. He will pardon us if we think that the nature 
of the case proves him to be mistaken, and that all experience confirms our 
opinion. Seest thou a man wise in his own conceit? there is more hope of 
a fool than of him." 

We proceed, now, to take a cursory view of the means which have been 
proposed for removing quackery. Our author alludes to the error which has 
induced some persons of benevolent disposition to believe that popular trea- 
tises upon anatomy, physiology, dietetics, &c., are adapted to prevent men 
from falling into the trap set for them by charlatans; he has no faith in their 
efficacy ; nor have we. 

" ' It is hardly credible/ says Frank, ' that an excessive and false philan- 
thropy Bhould so completely have blinded enlightened phj^sicians, as to have 
caused them to disseminate this vulgar error by publishing treatises on popular 
medicine,"by which incalculable mischiefs have been produced without the least 
necessity.^ * It is impossible to bring within the comprehension of the vulgar, 
a science which the study of a lifetime cannot exhaust.' " 

The doctrines of therapeutics have no direct connection with anatomy, 
physiology, and their kindred sciences. It is notorious that almost the only 
persons of note, in the medical profession, who have embraced the errors of 
homcBopathy, and other false systems, are not practitioners of medicine, so 
much as cultivators of the sciences which serve as an introduction to practice. 
So far from a popular knowledge of anatomy and physiology restraining 
quackery, 

" it sometimes evidently increases it, by giving its possessor an exalted idea 
of his medical acumen." " The only branches of medical knowledge," says 
Frank, " which it would be useful to popularize, are hygiene, and the duties to 
be rendered in cases of emergency, such as asphyxia, syncope, &c." 

Alive to the uselessness of attempting to remove quackery by such means. 
Dr. Hooker is for carrying the war into the enemy's country, and exposing 
the false conclusions which are the basis of quackery. He thinks that there 
has not been " enough of calm, candid, and patient discussion" of the subject, 
and too much of denunciation and calling hard names. We honour him for his 
temperate feelings towards even so unprincipled an enemy, but cannot augur for 



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him much success in his peaceful crusade. An invader never yet consented 
to retreat, on being politely expostulated with : the thief who breaks into our 
dwelling at night has earned, and we think ought to receive, the heaviest 
blows that can be dealt him; and we must believe that the abettors of such 
assailants have not much more claim to leniency than their principals. To 
reason with quackmongers and attempt to convert them to a more rational 
conduct, by showing them that even physicians commit the error of attributing 
results to causes which have no agency in producing them, is calculated rather 
to confirm them in their error than to convert them to the truth. 

Among other reasons for the failure of attempts to overthrow quackery, the 
following ought not to be forgotten. The credulity of the public mind 

" is encouraged by a similar credulity, existing to a considerable extent in the 
profession itself.'' ..." If the physician, for example, give full credence to 
all the juggleries of animal magnetism, and all the extravagances of phrenology, 
as they are put forth by travelling lecturers, how can he hope to dissuade an 
undiscriminating public from exercising a like credulity, in regard to the pre- 
tensions of quackery, which are not a whit more extravagant and fallacious 

We can only echo the question — how, indeed ? The same question is put 
in regard to the encouragement which secret medicines receive from some phy- 
sicians, and we can but sorrowfully repeat it. Then, too, there is the ^' spirit 
of quackery/' the habit of exaggerating the value of one's own skill, and the 
employing of various indirect arts to gain popular attention and applause, 
which encourage or excuse the artifices of downright quacks. This spirit, it 
is most truly said, 

" is not confined to a few of the ignorant and grossly unprincipled, who 
have stolen into our ranks ; but it is seen to a greater or less degree in the con- 
duct of some even who occupy stations of power and influence, and in quite a 
large portion of the common mass of practitioners." 

Alas ! how should it be otherwise when so few comparatively of our emi- 
nent physicians are willing to insist upon a thorough liberal education as a 
preliminary to medical studies, or to denounce the system of medical training 
which nine-tentJis of the schools furnish, as being, what it really is, a system 
for degrading science, and imposing upon the community physicians who pos- 
sess scarcely the first rudiments of medical knowledge ? How little en- 
couragement is held out to such as, from love of knowledge, or desire of dis- 
tinction, endeavour to obtain a thorough education ! how strong a temptation 
for them to abate their diligence, and cast in their lot with the mass who find, 
by a much easier path, both reputation and a competency ! 

The chapter entitled " Intercourse of Physicians," is an extended comment- 
ary on that part of the Code of Ethics of the American Medical Association 
which relates to this topic. Dr. Hooker highly commends this digest of 
professional duty, and has, indeed, printed it, as an appendix to his work. He 
introduces the subject by speaking of consultations, and points out, in clear 
and forcible language, the baseness either of violating the obligation to mu- 
tual respect, which lies upon physicians who attend the same patient, or of m. 
any way traducing a professional brother. Human nature is so feeble, and 
the occasions are so numerous in which a physician, if he be disposed, may- 
injure a colleague's reputation, that all writers upon medical ethics have 
dwelt strongly upon these points. We quote the following illustration from 

HUFELAND : 

" Oh ! that I were able to impress the minds of my brethren with the truth 
as forcibly as I am penetrated by it, that he who degrades a colleague degrades 



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himself and his art. . . . Such a character will be more lowered in the esteem 
of sensible men than he whom he endeavours to degrade ; for the detracted loses 
only as an artist, while lie loses as a man, and a bad action is esteemed worse 
than bad medical treatment. Finally, they should reflect, that the same mea- 
sure they apply to others is applied to themselves. He who treats others in a 
harsh and haughty manner may rest assured that he will be dealt with in the 
same way, which is but justice.'' 

" An honest and sensible physician,'' says Frank, " will never pass judg- 
ment on the acts of his brethren in the treatment of a case without having per- 
sonally witnessed it ; and even then, he will act with such prudence and extreme 
delicacy, as not to excite dissension, or by a hasty judgment to tarnish the 
honour of his colleagues." 

After enumerating and commenting upon the various cases which may arise 
in practice to test the character of a physician, our author alludes to the 
popular notion that medical etiquette" is some cumbrous ceremonial which 
clogs the freedom of a physician's actions, and ought, therefore, to be laid 
aside whenever the case in hand is really grave. This shows, amongst other 
things, how utterly misapprehended by the vulgar are the nature and objects 
of the medical profession. Medical etiquette is only a form of common 
honesty, and it were quite as just to bid one forget that he is an honest man 
when he is tempted to do wrong, as to beg the physician to forget the rules 
which have been framed to guide him in the intricate paths, and amidst the 
temptations, of his professional life. All moral law is favourable to freedom 
of action in the good ; it is a stumbling-block to the bad alone. So is it emi- 
nently true in this case that a strict adherence to ethical rules " favours free- 
dom of intercourse, by maintaining mutual confidence ; while a disregard of 
them destroys this freedom, by engendering mutual distrust.^' ■ 

The reasons why physicians are so generally thought to be jealous and 
quarrelsome are suggested to be the facility with which they can practice de- 
ception ; their opinions and their prescriptions must be taken upon trust, 
and consequently they are tempted to use various arts and manoeuvres which 
will not bear to be strictly examined, and which, when brought to the know- 
ledge of their brethren, are sure to be openly censured, but not always most 
emphatically by those whose own skirts are clearest. On the other hand, 
suspicion and accusation of wrong are often entertained against parties who 
are wholly innocent, upon no better ground than the misrepresentations of 
some impudent meddler, or some well-meaning friend. Here are seeds 
enough of discord without searching for more. Much as we have to deplore 
of unkind feeling amongst physicians, and of unjust judgments passed by 
them upon the conduct of their brethren, there is not, we are satisfied, so 
much of either amongst us as the following extract from Simon's work as- 
cribes to the profession in France : — 

" We have spoken of medical brotherhood ; medical brotherhood ! That is 
doubtless something mythological, or perhaps an antediluvian tradition. Two 
physicians, indeed, advancing side by side without envy, aiding one another by 
their knowledge, and mutually defending each other against the prejudices of 
the public ! That would be an unheard-of prodigy : the whole medical pro- 
fession would look upon it as not less a curiosity than were once upon a time 
the dwarf Ritta-Christina and the giant Teutobochus." 

There can be no doubt in the minds of any who have observed the medical 
profession in Europe, that a very large portion of it is inferior to our own in 
the qualities which sliould distinguish gentlemen; that it is characterized by 
a much lower notion of personal dignity and honour than American physi- 
cians entertain ; and that its conduct is much more frequently tarnished by 



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meanness and sordidness of sentiment. The reason is perhaps not difficult to 
discover. In the United States, the liberal professions contain the real aristo- 
cracy of the nation, and medicine numbers amongst its cultivators and prac- 
titioners thousands who occupy the highest social rank. In Europe, on the 
other hand, there is first the titled nobility, then the army and navy, the 
clergy, and the bar, who all outrank the medical profession, because through 
these pursuits alone is the road open to political preferment. They absorb 
nearly all the young members of respectable families, and the ranks of medi- 
cine are chiefly recruited from the humbler classes of society. It is not, 
therefore, to be wondered at that, in point of personal character, of honourable 
sentiment, and of dignified demeanour, the medical profession of the United 
States ranks the first in the world. These peculiarities are sufficient to ex- 
plain why a judgment like that above quoted from Simon is clearly inappli- 
cable to American physicians. They also explain why the principle of asso- 
ciation, and the habit of harmonious action, are so effective and prevalent 
with us, and so rare in transatlantic communities. Of these, the English 
approaches nearest to our own in organization, and the English physicians 
excel all others in Europe in their social rank^ and their sense of personal 
dignity.* 

By these remarks, we. have no intention of proclaiming the complete 
exemption of our medical countrymen from the low tricks and sordid aims 
which are too common in other countries, much too common in our own, 
but only to maintain that, as a profession, we are not justly chargeable 
with them. Our author points out a number of particulars in which not a 
few of our brethren err, and supply but too real grounds for a "railing accusa- 
tion." We can only enumerate them : Professional cliques, and alliances 
with various societies, social, moral, or religious ; controversies upon medical 
subjects; the interference of physicians with one another's practice; these 
are forcibly dwelt upon as some of the means by which the harmony of the 
profession is disturbed, and modest merit condemned to languish, while 
mediocrity grows prosperous upon the fruits of shameless presumption com- 
bined with artful sycophancy. 

The chapt^ on "Interference with Physicians" is addressed chiefly to 
non-professional readers, and we shall not, therefore, dwell upon its contents; 

* We cannot resist the temptation of quoting the following passage from a paper read 
before the Academie de Medecine, by M. Roxer Collaru, one of the most eminent and 
honourable physicians of France. It proves that, if we are behind other nations in 
scientific pursuits, we have nothing to envy one of the greatest so far as concerns the 
dignity of the medical profession. The paper in question contains the author's views 
on the necessity and the means of repressing quackery. It was read before the Aca- 
demy in May, 1842. "We complain,'' he remarks, "of the negligence of the govern- 
ment which tolerates the encroachments of charlatanism, and of the law which, by its 
silence, secures to them impunity. But we, what are we doing? Heaven only helps 
him who helps himself! Now what efforts are we making in the midst of this wreck, 
which is engulfing the honour of our profession as well as the good of society? I 
will go still further : are we ourselves, all of us, and always, irreproachable ? Cast 
your eyes over the disgraceful columns which close the daily papers; the letters, the 
prospectuses, scattered by thousands from one end of France to the other; do you not 
constantly find amongst them laudatory certificates, written and signed, I am obliged to 
say it, by the most respectable physicians? How could it be expected but that the pub- 
lic should be duped by the names of physicians whom it has learned to respect? 
What might I not say, were I to point out quackery wherever it insinuates itself, con- 
cealed under every shape ; sometimes under a scientific veil, sometimes with an affecta- 
tion of austere severity, stealing into the profession itself, into colleges, into the concours, 
and I add, in a whisper, even into the Academies?" 



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but we cannot avoid quoting an anecdote, which shows that a man is now and 
then to be found, ready and able to silence the vulgar abuse of which we are 
so often the object in courts of justice, on the part of those charlatans in law 
who seem to think that an advocate is no longer a man, but a mere machine, 
without conscience or responsibility. 

" A very severe rebuke was once administered by a judge in Massachusetts, 
to a lawyer, for hinting at the charge of mal-practice against a physician who 
was one of the parties in a case before the court. The insinuation was intended 
as a sort of make-weight for the advantage of his client. The judge at once 
inquired of the lawyer if he intended to make that a point, giving him to un- 
derstand that, if he did, he would be expected to produce evidence bearing upon 
it. The lawyer said that he did not. ' You will withdraw that point, then,^ 
said the judge, ' and indulge in no further remarks upon it.' Very soon, how- 
ever, he made the same insinuation again. The judge interrupted him, and 
remarked that, as a professional man's reputation was of the highest value to 
him, and was even the means of his livelihood, he would not suffer it to be 
wantonly attacked in any case ; and he told the lawyer that, as he had twice 
brought the charge of mal-practice against this physician, he should not per- 
mit him to go on with his plea till he had withdrawn it in writing," 

Our author very properly rebukes those who are so ill advised as to criticize 
the treatment under which patients have been placed, and who relate the 
wonderful cures which this or that remedy, or their favourite physician, has 
performed. Nothing can be more impertinent, nothing more cruel, than the 
conduct of such meddlers. They are to be found in all classes of society, but 
most of all among those who are, if possible, the most ignorant of what they 
profess to know. Scoutetten stigmatizes their mischievous interference, but 
shows, by the following quotation, that the evil is not of modern date : — 

" Fingunt se cuncti medicos, idiota, sacerdos, 
Judaeus, monachus, histrio, rasor, anus. 
Miles, mercator, cerdo, nutrix et arator; 
Vult medicas hodie quivis habere manus." 

The following chapter is one of the most interesting in the work before us. 
It is entitled, " The Mutual Relations of the Mind and Body in Disease," and 
treats of this subject in a most thorough and comprehensive manner. We 
are well aware that many physicians regard their patients as a chemist does 
his retorts, as mere receptacles, in which a certain something, the disease, is 
to be acted upon by certain other bodies, medicines, and that certain reactions 
succeed, which end in the production of a neutral state, or health. Our author 
does not forget that when man was created, he became a living soul,'' and 
that neither soul nor body can change the normal conditions of its existence 
without acting upon the other. He who practices medicine without keeping 
constantly in view the mutual dependence of these two elements of our being, 
is but half accomplished in his art, and must vainly attempt by drugs to effect 
what a few words spoken in season would have accomplished. Here, too, is 
a broad distinction between the charlatan and the acute physician ; for the 
former loses all the advantage which the latter possesses in virtue of his sym- 
pathy, and his intelligent employment of mental influences. Yet we often 
witness the surprising power of knavish quacks over the sick, derived from 
the positive assurances of success, which they do not hesitate to give in cases 
which a physician knows must ultimately be fatal. Physicians ought, there- 
fore, to keep constantly in view the mental peculiarities of their patients, and 
never to lose an opportunity of influencing the minds of the sick and giving 
them a tendency towards safety. In truth, everything that is said or done 



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"in the sick room, is to be regarded as really a medicine, and producing as 
real if not as manifest effects upon the state of the patient as any of the 
drugs administered." 

In pursuing this subject, our author furnishes copious and striking illus- 
trations of the mental reactions of mind and body, and very properly rebukes 
the extreme notion to which a desire to avoid materialism has given currency, 
that mind and body are two separate and independent things. Whatever 
may be their mutual relations, certain it is that neither one can act or suffer 
without the action or passion of the other. Nor is it only the immediate in- 
strument of the soul, the brain, which enters into mutual reactions with 
thought and emotion, but several organs seem to be so directly acted upon 
by these latter, that, as the author points out, this fact gave rise to the revival, 
by Bichat, of the doctrine that the moral sentiments were actually seated in 
the ganglia which supply the great organs of the trunk. 

** There is no evidence," he further remarks, " of the existence of one great 
central point of attachment for the mind, but the ties of its connection with 
the body are multiplied and diifused. It is not merely, therefore, positive 
disease existing in the brain that affects the mind.'' 

Weakness of mind nearly always attends feebleness of body in acute dis- 
ease, and the strongest intellects turn in despair from subjects which would 
appear simple to a child. It therefore becomes a matter of the highest 
moment, to regulate all the mental influences to which the sick are subjected; 
and, above all, to exclude everything which in the smallest degree tends 
either to exhaust them, or to excite disagreeable emotions. Even children 
are often injured by the disquiet and the conversation around their sick beds; 
they are scarcely less susceptible than adults to the injurious impressions 
which the comments of visitors are in danger of producing. On the other 
hand, the minds of sick persons often require the stimulus of conversation ap- 
propriate to their case, when they have sunk into dull despondency, or are pre- 
occupied with some erroneous idea. It needs great skill and knowledge of 
human nature to manage such cases properly. 

*' All direcf and palpable eff'orts to make the gloomy invalid cheerful are 
almost always unsuccessful ; and yet it is such efforts that are most commonly 
made use of by the friends of the sick." 

We cannot follow our author through the whole of this chapter, which we 
earnestly commend to the careful study of physicians; but close our notice of 
it with the following extract : — 

" The physician should be something more than a mere doser of the hody. 
Mental influences are among the most important of our appliances in the cure 
of diseavse. The physician, therefore, in fulfilling his high vocation, should not 
only have a full knowledge of mental philosophy, but he should aim to acquire 
a practical skill in applying its principles to all the ever-varying phases which 
the mind presents in its connection with disease. The possession of this skill 
is one of the most valuable endowments of the medical art." 

The chapter on " Insanity" appears to be adapted to popular rather than 
professional readers; but the legal relations of the subject are treated at some 
length, and with a special reference, it would seem, to the injustice which is 
committed by our tribunals, in not according to the plea of insanity its proper 
value. In this country, the physician v/ho is called into court to testify to 
the credibility of such a plea, comes as a witness biassed in favour of one side 
or the other. We have even seen him, moved by his convictions or his per- 
sonal interest in the accused, lay aside the character of witness for that of an 



170 



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[Jan. 



advocate, and convert his testimony into an eloquent and pathetic plea. All 
this is wrong. The physician is summoned, in such cases, not as an advocate 
but as a judge, and he should advance to his conclusion with the cool delibera- 
tion of one who is entirely ignorant of the consequences which it may entail. 
The plea of insanity has been so often set up and so frequently sustained by 
opinions of a character wholly ex parte, that both the public and persons of 
judgment have begun to regard it as a lawyer's trick, and are disposed to dis- 
trust its soundness in all cases. We do not know of any case in which, to 
use our author's words, " life itself has been sacrificed, under all the solemn 
formalities of law, for acts committed in the irresponsible condition of in- 
sanity,^^ but it is notorious that some murderers have escaped punishment 
upon this plea. It is high time that an end should be put to the wrongs 
which individuals or the public sufi'er, by the loose manner in which the plea 
of insanity is set up in courts of justice, by making those who are to decide 
upon the mental condition of the accused, officers of the court for the time. 
In France, where this system is adopted, the physicians charged with this 
duty approach the prisoner at all times, and, as Dr. Bell, of Boston, de- 
scribes their functions, 

" Watch his actions in his presence and without his knowledge ; his habits, his 
sleeping and waking hours, his physical condition. Everything, in fact, which 
can throw light upon the momentous question, passes under slow, persevering, 
scientific investigation. Under the responsibility of reputation as precious to 
them as those of the highest court, and under the sanction of an oath, they 
arrive at conclusions, and present their reasons for such conclusions, which 
form one, not the exclusive, element for a court and jury to arrive at a just 
judgment.^^ 

If such care were taken by our courts to procure the opinions of medical 
experts, we should have no occasion to deplore with our author the capital 
condemnation of an irresponsible homicide, or the decision of a jury, which 
restores to liberty one whom the most skilful and conscientious physi- 
cians have pronounced insane. One would suppose that the innate love of 
justice which characterizes our people, and the leaning towards mercy which 
is constantly rendering our penal code less severe, would have led us amongst 
the first to legislate for the insane accused of crimes; yet in this respect we 
still remain behind European nations, and are every day committing acts of cruel 
injustice towards either the community or the accused in criminal procedures. 

In Chapter XVI. Dr. Hooker illustrates, by many sound considerations 
and several apt examples, the salutary influence of hope in promoting the 
recovery and prolonging the lives of the sick. 

" Every medicine that is given,^' he remarks, " should be administered by 
the hand of hope. The prospect at least of relief, and generally of recovery, 
should be held up to the mind of the patient." " Even in those cases in which 
the physician feels it to be almost certain that the final issue will be a fatal 
one, it is nob proper to give up wholly the idea of recovery, in his conversations 
with the patients or with his friends." 

For the number of cases in which death is absolutely certain to occur within 
a given time is extremely small, when compared with those in which the 
issue is altogether doubtful, or is at least uncertain to take place by a fixed 
period. In these latter, to pronounce a positive sentence of speedy dissolution 
is as cruel to the patient and as wicked for the physician as if he had violently 
extinguished the lamp of life. But this is a very different thing from giving 
utterly false assurances to the sick. 

" The former can be consistently done by the upright and high-minded prac- 



1852.] 



Medical Ethics. 



171 



titioner, but the latter is to be expected only in the ignorcant pretender, and 
the dishonourable and unprincipled physician/' 

This doctrine is not of universal acceptation; and therefore^ in the following 
chapter, the author applies himself to the consideration of the subject embraced 
in the question, Whether there are any cases in vihich^for the sake of benefit- 
ing our fellow-men^ 'perhaps even to the saving of life^ it is proper to make an 
exception to the great general law of truth." 

This question is not a novel one. In the " Elysius Jucunclarum Quedss- 
tionum," by Franco, a Spanish physician of the 17th century, it is treated 
with ample details; and we refer to his work in this place because it contains 
a summary of the opinions of G-reek and Roman writers, which may be profit- 
ably compared with those who have flourished under a purer form of faith. 
According to Galen, " If the patient is courageous, he should have the whole 
truth told him ; but if foolish and timid, everything should be done to keep up 
his spirits, yet without greatly lying. If, however, his alarm is so extreme 
that you feel constrained to promise him certain recovery, at least let his 
friends know the truth.'' " When the case is an extremely dangerous one," 
says Celsus, " yet not desperate, the near friends of the patient should be in- 
formed thereof, lest it seem that the physician's skill was at fault, or that 
he did not know the truth." Elsewhere, the same author advises that the 
patient be soothed with words that " have the semblance of truth." Damas- 
CENUS advises ^'to promise the patient recovery, even though you should 
despair." Rhazes declares that " the sick are to be encouraged, even when 
signs of dissolution appear." Plato decides that physicians may be al- 
lowed to deceive, but none others whosoever : for, in order to sustain the 
sinking courage of their patients, they must often promise recovery during the 
last agony." " All the ancient authorities," continues the writer from whom 
these passages are taken, " look upon the announcement of death as so terrible, 
that not only would those about the sick to whom it is made take it very ill, 
but even inveigh against the physician as the author of their friend's dis- 
solution." " Religious and theological writers, on the other hand, maintain 
that patienl^ should be warned to prepare for death. The G-reeks and 
Romans gave such advice as has been quoted, because they had no knowledge 
or hope of immortality, but it is evident that the disciples of a faith which 
looks upon this world merely as a preparatory stage to eternal life, should 
believe that the fear of death ought not to prevent preparation for eternity. 
. . . Yet the physician is not to be in haste to announce death, nor to do so 
rudely or pompously, and least of all to the patient himself. And if, from 
the feebleness and dejection of the patient's mind, he should infer that his 
own announcement of danger would be injurious (for some have recovered at 
the last gasp, who would certainly have been destroyed had the physician 
communicated his apprehensions), he ought to have him warned by the 
minister of religion, or by pious persons. For this is always better than to 
keep silence on so momentous a topic." The contrast between the heathen 
and the Christian estimate of the subject displayed in the foregoing quota- 
tions is very striking, and arises, we can hardly doubt, from the fact that the 
latter is based upon the doctrine of the nothingness of earthly things when 
compared with the substantial joys of a future state of existence, while the 
former is derived from the belief that man's chief end is to be fulfilled on 
earth. 

The general tone of modern writers who have treated of this subject agrees, 
on the whole, with that of the author last quoted; yet they are by no means 
unanimous. The subject is an interesting one, and we suspect that the 



172 



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[Jan. 



reader will not be displeased to know the opinions of authoritative writers 
concerning it. We shall cite those which are regarded as most conclusive 
on either side of the question. 

Gregory says : " A deviation from truth is sometimes in this case both 
justifiable and necessary/' as when the patient may recover if he is not in- 
formed of his danger. " But in every case it behoves a physician never to 
conceal the real situation of the patient from his relations.' ' Hufeland is 
still more explicit ; he says : — 

" A physician must never forget that nothing ought to emanate from him 
which may have the effect of injuring the patient or of shortening his days ; 
every word, every look, his whole conduct, must be of an enlivening tendency. 
.... The physician must be careful to preserve hope and courage in the 
patient's mind, represent his case in a favourable light, conceal all danger from 
him, and, the more dangerous it becomes, show a more cheerful appearance. 
.... He can guard himself from the suspicion of not having fully appreciated 
the nature of the case, by giving a true description of the patient's situation 
to the relations, and, if they be fickle and negligent, by stating it rather darker 
than lighter. . . To announce death is to give death, which is never the business 

of him who is employed to save life It is not life alone, but what is still 

more, reputation, that the physician must risk when the life of a sick person 

is at stake The honest physician knows of no other consideration than 

benefiting the sick. . . . Therefore, he does not hesitate to use also this last 
resort in order to save his patient, and will either enjoy the triumph of seeing 
his honest attempt crowned with success, or the still greater triumph of having 
sacrificed to his duty that which is most dear to him.'' 

The English editor of Hufeland's tract is of opinion that, had the above 
passages " been further expanded and illustrated, it would have turned out 
that his difference with the venerable writer was more apparent than real.'" 
We can hardly adopt such an exposition, inasmuch as the language of the 
text appears to us too plain and explicit to be interpreted in accordance 
with the more commonly accepted and safer doctrine. In several passages 
of his Deontologie, Simon appears to furnish nearly similar precepts to the 
above. Thus, when speaking of the conduct which a physician should hold 
during the prevalence of epidemics, he says, " whatever his personal con- 
victions, or even his conjectures, about the nature of a prevailing disease, 
he ought on all occasions to pronounce it non-contagious." Again, in a 
passage bearing more immediately upon the present subject, he thus expresses 
himself : " Most of those who are suffering from incurable diseases cling to 
the hope of recovery even until death, and the physician cannot, without 
cruelty, dissipate this hope, however unfounded it may be." Yet, in another 
place, he would appear to qualify this general precept; for, admitting that in 
certain cases of inevitable death the patient should be informed of his situa- 
tion, the author is of opinion that the physician is not the proper person to 
discharge this delicate duty. " His function of benevolence forbids him to 
employ any language, or to do any act, to disturb the mind of the unhappy 
sufferer.'' Another person may inform him of his danger without robbing 
him of all hope, " but, in the mouth of a physician, the same words may, 
like a thunder-bolt, at once break asunder the cords of life." 

The last authority whom we shall quote upon this side of the question is 
Percival, whose doctrine is made the subject of an extended commentary 
by our author.*' It is embodied in the following sentences, i^fter citing as 

* We are unable to liarmonize the doctrine of this passage with that of the same 
author embodied in our National Code of Meciical Ethics, and whicli is quoted further 
on. The passage is contained in the notes appended by him to liis Code. 



1852.] 



Medical Ethics. 



173 



an axiom the golden rule, Do unto others as ye looidd tliat they should do unto 
you^ he proceeds: ''To a patient, therefore, perhap3 the father of a family, 
or one whose life is of the highest importance to the community, who makes 
inquiries, which, if faithfully answered, might prove fatal to him, it would be 
a gross and unfeeling wrong to reveal the truth. His right to it is suspended, 
or even annihilated; because, its beneficial nature being reversed, it would be 
deeply injurious to himself, to his family, and to the public." Subsequently, 
the author guards this precept by declaring that it should not be appealed to 
except '' in cases of real emergency." Here the doctrine is stated in its 
boldest and most naked form, but, as is evident from the context, with a sin- 
cere and earnest desire to avoid wounding the cause of truth, or opening the 
door to a licentious disregard of its authority. 

Before presenting the commentary of Dr. Hooker on the above passage, 
we shall cite several authorities who adopt views opposite to those which have 
been quoted : — 

" When," says Frank, '' all hope of cure is lost, the physician ought to 
convey the information with extreme caution to the relatives and friends, and 
even to the patient himself if he should request it, and if it may be done 
without injury." Dr. Mackness considers with some fulness the interesting 
question before us: "Is it lawful," he asks, "to do evil that good may come? 
We think not; and whether the expected good does, in the long run, result 
from a direct violation of the great and eternal principles of truth, is very 
problematical. We see no reason why a, medical liar should be exempted from 
the common and ancient experience, that liars are not always believed, even 
when they speak the truth. .... Dr. Samuel Johnson, with his character- 
istic straightforwardness, says : " You have no business with consequences; you 
are to tell the truth." .... GtISBORNe speaks to the same effect: "The 
physician may not be bound, unless expressly required, invariably to divulge, 
at any specific time, his opinion concerning the uncertainty or danger of the 
case; but he is invariably bound never to represent the uncertainty or danger 
at less than ^e actually believes it to be : he is at liberty to say little, but 
let that little be true.'' .... "It often happens (says Dr. Watson), that a 
person is extremely ill, and in great danger, but yet may recover, if he is not 
informed of his peril. To tell a person in these circumstances that he is likely 
to die, is to destroy his chance of recovery. You kill him, if you take away 

his hope of living If I see that a case is absolutely and inevitably 

mortal, either soon or at some little distance of time, I leave it to the discre- 
tion of the person with whom I communicate, to disclose or conceal my 
opinion, as he or she may think best." 

In the next chapter to that under notice at present. Dr. Hooker expresses 
sentiments almost identical with these. " The physician," he remarks, " should, 
even in desperate cases, avoid producing the impression upon the mind of the 
patient that he really believes the case to be hopeless. Nothing but the most 
absolute certainty would warrant his doing this. The cordial influence of 
hope is often one of the means by which a recovery is effected, and the ab- 
sence of this one means may prove fatal." 

The last authority we intend to cite in reference to the present question, is 
the Code of Medical Ethics of our own National Association, which, it will be 
perceived, harmonizes with those last quoted. It is borrowed from Percival. 
" The physician should not fail, on proper occasions, to give to the friends of 
the patient timely notice of danger, when it really occurs ; and even to the 
patient himself, if absolutely necessary. This office, however, is so peculiarly 



174 



Review. 



[Jan. 



alarming wlien executed by him, that it ought to be declined whenever it can 
be assigned to any other person of sufficient judgment and delicacy." 

In considering further, with Dr. Hooker's guidance, this delicate subject, 
it should be distinctly understood, that the question is not whether we are at 
liberty to conceal the truth, but whether, in doing this, we are permitted to 
set a falsehood in its place. We have seen that many wise and good men 
maintained the affirmative proposition, and we know that many still act in 
conformity with it. Their character absolves them from all suggestion of 
criminality, although their actions may have been mischievous in their tend- 
ency. Whether they were really so or not, the reader may judge in the 
light of Dr. Hooker's commentary. He remarks, in the first place, that "it 
is erroneously assumed by those who advocate deception, that the knowledge 
to be concealed from the patient would, if communicated, be essentially inju- 
rious to him." This assertion is alleged to be far from warranted by facts. 
" It is also erroneously assumed that concealment can always, or generally, 
effectually be carried out." But this is evidently not the case, and an acci- 
dental discovery by the patient of the truth would have infinitely graver con- 
sequences than its judicious announcement. " The destruction of confidence, 
resulting from discovered deception, is productive of injurious consequences 
to the person deceived." This is strikingly true as regards children, for they 
cannot, like adults, appreciate the motives of such a deception. "The general 
effect of deception, aside from the individual which it is supposed it will 
benefit, is injurious." It weakens the confidence which it is so soothing for 
the sick to feel in those around them, and so impairs many of the influences 
which might be usefully employed for their benefit. Thus it is that 
small events ripen into vast consequences. " If it be adopted by the commu- 
nity as a common rule, that the truth may be sacrificed in urgent cases, the 
very object of the deception will be defeated." This proposition is self-evi- 
dent. " Once open the door for deception, and you can prescribe for it no 
definite limits." In summing up his arguments upon these heads, the author 
thus concludes : — 

I think it perfectly evident that the good which may be done by deception 
in 2i,few cases is almost as nothing compared with the evil which it does in many 
cases, when the prospect of its doing good was just as promising as it was in 
those in which it succeeded. 

It is always a question of expediency simply, whether the truth ought to 
be withheld. And it is a question which depends for its proper decision upon 
a variety of considerations in each individual case. The obvious rule on this 
subject is this — that the truth should not be withheld unless there be a reason- 
able prospect of effectually preventing a discovery of it, and that, too, by fair 
and honest mgfins." 

On a review of the whole of this subject, we are led to the following con- 
clusions : 1st. Absolute truth should be the rule of our intercourse with the 
sick. 2d. Exceptions may exist to this rule as to every other — i. e. it is 
forbidden to kill, but it is lawful to do so in order to save a life that is 
menaced by a murderer. 3d. Deviation from truth in any other than such 
rare and altogether exceptional cases, is in the highest degree culpable, and 
would lead, if permitted, to the destruction of all confidence in physicians, 
both professionally and as men. 4th. It is not possible to specify, before- 
hand, the circumstances in which either one of two conflicting moral laws 
shall be permitted to have the ascendency. But whenever, in the practice of 
medicine, such a conflict arises, physicians are bound, by every principle of 
honour, morality, and religion, to examine thoroughly all the circumstances 



1852.] 



Medical Ethics. 



175 



of the individual case, and decide according to the true advantage of their 
patients. 

Chapter XYIII. on the " Moral Influence of Physicians," is one of the 
most interesting in Dr. Hooker's work. It points out the tender and intimate 
relations in which a physician stands to his patients, and the gentle and 
humanizing influences on his own character, which his office of consoler and 
benefactor must exert. It has often been alleged by those who are unable to 
appreciate all that this office confers of true benevolence, that the physician 
must become hardened and unfeeling by his perpetual contact with the sick 
and dying. If all history and all actual experience did not prove that phy- 
sicians are continually to be found as the most active and successful pro- 
moters of beneficent enterprises, the least consideration of the nature of their 
duties would prove that they, of all men, are most likely to have developed 
whatever qualities most adorn and dignify the human character, and open in 
the heart those springs of benevolence which refresh and fertilize the waste 
places of humanity. True, the physician will not, as our author remarks, 

have that mawkish sensibility which vents itself in sighs, and expressions 
of pity, but stops short of action,'' but he will be filled with that pity, and 
sympathy, and kindness, that passes by no sorrow which it may console, and 
that leaves no suffering unrelieved. The benevolence which, instead of bar- 
ren pity, gives relief, and instead of tears alone pours the oil of healing into 
the wounded heart, is likest to the divine mercy, whose existence is revealed 
by acts alone. The habit of doing good becomes a part of his nature, and is 
more beautiful when its genial refreshment falls like the dews of heaven upon 
the sufferer, than if it descended like the storm of rain, prostrating more than 
it revives. Susceptibility of character is no proof of benevolence, but is often 
found allied with the most calculating selfishness; its possessor finds no wor- 
thier object of sympathy than himself, and he will mourn profusely over his 
own real or fancied pains, though he should refuse a tear to the sufferings of 
his fellow-men. Without doubt, the medical profession includes a great many 
persons who are pre-eminently merciless and selfish, for it cannot transform 
devils into angels of light; but its whole history, and the slightest acquaint- 
ance with its actual members, suffice to prove that it tends to humanize many 
hearts to which nature has been sparing in her gifts, and to expand and enno- 
ble beyond example those whose native tendencies are towards good deeds. 

In his concluding chapter. Dr. HooKEfi enumerates the trials and pleasures 
of the physician's life. Of the former, the number is great; and unfor- 
tunately we are so constituted that we seldom forget what we have suffered, 
but the daily and hourly blessings we enjoy leave hardly a more lasting im- 
pression upon our hearts than a ship's keel upon the sea. The genial sun- 
shine, the gentle dews, the springing flowers,, and slow maturing fruits, which 
give us life, and food, and health, are forgotten with the moments when they 
were enjoyed, but we never forget the calamities which attend upon their pri- 
vation. It is well, therefore, that, along with a catalogue of the grievances 
which as physicians we are compelled to bear, we should be furnished with a 
remembrancer of the many joys and privileges which are incident to the 
medical profession. 

The physician is indeed the slave of his fellow-men. His time is not his 
own, no, nor yet his life. At all times, in season and out of season, by day 
and by night, he must sacrifice his own comfort to lessen the sufferings of his 
fellow-men, and when prevailing disease spreads terror through the commu- 
nity," he must be at his post and expose himself to the pestilence. Well 



176 



Review. 



[Jan. 



might Hoffman exclaim, " A practitioner's existence has good reason to be 
held the most miserable of all. He is the slave of slaves; his whole time is 
taken up in lengthening the life of others, and in shortening his own/' Casper, 
of Berlin, has demonstrated that, in point of longevity, physicians come not 
only after theologians (who live longest), but also after merchants, soldiers, 
lawyers, artists, and literary men." 

Physicians are, in general, poorly compensated. A large proportion 
of their patients feel a less urgent obligation to pay them than they do 
to pay others. I know not any other reason for this, than the intangibility 
of the favour which is bestowed by the physician,'' The physician, too, is 
perpetually exposed to have his feelings, as a scientific and benevolent man, 
wounded by the desertion of his patients to the ranks of quackery, and to wit- 
ness the sacrifice of their lives or health at some impostor's shrine. He has 
enough to bear in feeling the impotence of art in but too many cases, without 
being subjected to the mortification of seeing that all his care and skill have 
failed to inspire confidence or respect. He is also subject to the pain of finding, 
even in acute diseases, the most skilful and judicious treatment fruitless; and, 
in chronic affections, he is constantly called upon to sufier a real bereavement 
in the death of patients, between whom and himself an attachment has grown, 
out of their thankfulness for his good offices, and his admiration of their 
gentleness, patience, and resignation. "One of the greatest trials which the 
physician has to bear is the ingratitude of those upon whom he has conferred 
favours." In fact, as our author remarks, the strongest evidences of this 
feeling proceed from those upon whom he has conferred the highest favours, 
perhaps those which are entirely gratuitous. It is, indeed, notorious that 
charitable services are very seldom repaid by gratitude, and that, of all the 
means by which a physician's practice is increased, the recommendation of 
those whom he has befriended is the most insignificant. Indeed, such is the 
perverseness of human nature, that we have known a physician to be depreciated 
by persons on whom he had lavished year-long attendance, as a sort of ven- 
geance for his daring to bestow charity upon them. Our author truly says, 
" There is not as much gratitude in the world as is commonly supposed." An old 
physician of his acquaintance used to classify the poor thus : " the Lord's poor, 
the devil's poor, and poor devils." Of these, the last are too lazy to experience 
so lively a feeling as gratitude, and the second are too vicious ; the remaining 
small class afibrd, perhaps, more of the consolations of which a physician stands 
in need than all his other patients together. They are not so rich as to be 
humbled by receiving a favour, nor so proud as to resent its reception. The 
spirit of the age is hostile to such a feeling as gratitude. Our institutions, it 
must be confessed, are mortal to it. To be convinced of this sad truth, one 
has but to compare the manners of the recent emigrant, who is eloquent in 
thanks to the physician who has rescued him from typhus or some other grave 
disease, with the surly, half-insolent manner in which the same individual will, 
a few years later, receive, but not requite, the like services. 

The clerical profession must be added as another class from which physicians 
too commonly receive ingratitude and injury in return for the gratuitous ser- 
vices which they have rendered without stint. The author speaks more in 
sorrow than in anger of this unnatural conduct, which admits neither of excuse 
nor palliation, and which he justly reckons " among the most vexatious trials 
of a medical life." But it is only one of the thousand analogous sufferings 
which the ingratitude of mankind inflicts upon our profession. At every step, 
and from every rank in the community, we are compelled to receive evil for 



1852.] 



Medical Ethics. 



177 



good, and to witness the bestowal of panegyric and reward upon every class 
but our own. 

A most flagrant and memorable illustration is furnished by Dr. Hooker. 

" After the yellow fever of Philadelphia, in 1798, had subsided, at a meeting 
of the citizens, in which the committee who superintended the city during the 
prevalence of the disease was honoured with a vote of thanks, a similar vote 
was proposed in rehation to the physicians, but was not even seconded, though 
nearly one-fourth of their number perished in their efforts to save that ungrate- 
ful people from the ravages of the pestilence !" 

As a pendant to this picture, we present the following: "During the 
'famine fever' of 1847, in Ireland, one hundred and seventy-eight Iriah medi- 
cal practitioners, exclusive of medical pupils and array surgeons, died, being 
a proportion of 6.74 per cent., or one in every 14.83 medical practitioners in 
a single year'^ (Lancet, vol. i., for 1848, p. 186). Yet we have never heard 
that any memorial was consecrated to their honour, or that the wives and 
children of these noble martyrs had even one penny allotted to them by the 
government, at whose call their husbands and fathers laid down their lives as 
an offering upon the altar of humanity. 

The heart sickens at such details, and we gladly turn from them to glance 
at the pleasures and rewards which the upright physician may enjoy. But 
whether these be great or small, it should never be forgotten that there is, 
after all, but one among them which can atone for the pains and trials of a 
medical life, and that is, the consciousness of having performed one's duty. 
As it is the only full and complete remuneration possible, so is it the only one 
which it is not in human power either to give or to take away. Whoever looks 
exclusively to any other reward will, beyond all peradventure, be grievously 
disappointed; and whoever limits his ambition to this difficult achievement 
will find that he possesses a charm which will heighten the joys of the most 
eminent prosperity, and sweeten the bitterest cup which adversity may oblige 
him to drink. 

The pleasures of a medical life are, indeed, various, and precious to him who 
has the faculty of appreciating them. Our author points out several of the 
most striking. It will be seen, however, how totally unsatisfying they must 
be to men of vulgar tastes and narrow minds. Medical science is, beyond 
comparison, the most engaging of all, because, if for no other reason, upon 
it every other science sheds light ; but it is rendered even more attractive by 
leading directly to the improvement of the most necessary and beneficent of 
human arts. The exercise of this art must be pre-eminently delightful, since 
it enables the physician to save life, to alleviate pain, and indirectly to diffuse 
joy through families which had else been made desolate. No wonder that 
the habit of producing such results should render the physician " a hope- 
ful, a cheerful, a happy man." The kindness and affection, too, which are 
so often shown him, the tokens of gratitude which he sometimes receives, his 
position as a confidential friend and adviser, the homage which so many per- 
sons are in the habit of paying to his authority ; these are pleasures which go 
far to make him forget the ingratitude and disrespect which it is too 
often his lot to experience. No man is so welcome as he in the domestic 
circle; his learning or accomplishments render him an honoured guest 
to the cultivated and refined, and his knowledge of human nature makes 
him at home among the humblest ranks of society. No other human being 
is assured, like the physician, of a cordial welcome wherever he may go ; none 
other can enjoy the consciousness of having carried the light of hope into so 
many hearts, or look back upon the experience of a lifetime so replete with 



178 



Review. 



[Jan. 



good and useful deeds. Such reflections should yield support and consolation 
to all who are ready to faint under the trials which the practitioner of medicine 
cannot altogether escape. When he is weary with fatigue, stung to the heart 
by ingratitude, oppressed by his sense of responsibility, in despair at the slender 
returns of his painful toil, and shocked at the empire which false systems are 
gaining over the community ; let him turn to the bright and genial image of 
his noble profession, which, like an incarnate Providence, is glorious with all 
human wisdom, and beneficent with more than human bounty — the profession 
which furnished one, the only one, of whom the greatest of rulers could say, 
" he was the most upright man that I have ever known."* A. S. 



* Napoleos" bequeathed to Larhet 100,000 francs, with this sentence. 



1852.] 



179 



BIBLIOGRAPHICAL NOTICES. 

Art. XYI. — Surgical Anatomy. By Joseph Maclise, Fellow of the Royal 
College of Surgeons, of England. Part V. : Blanchard & Lea, Philadelphia, 
1851. 

We have, in several of the preceding numbers of this Journal, laid before 
our readers a sketch of the contents and character of Mr. Maclise's book, as 
the successive parts were published. The fasciculus now before us forms the 
conclusion of the work, and we take pleasure in announcing the topics which 
it embraces. 

The last plates of the fourth part exhibited numerous representations of 
mal-conditions of the urinary and generative organs of the male. Additional 
illustrations, sixteen in number, of organic derangements of the urinary blad- 
der, are displayed in the first two plates of this portion of the book. The 
author assures his readers that these drawings have been taken by himself 
from morbid specimens contained in the museums and hospitals of London 
and Paris. The bladder is shown as deformed by sacculi, due to protrusions 
of the mucous membrane between fasciculi of the muscular coat of the organ, — 
occasioned either by the opening of abscesses into its cavity, or by the efforts 
of the bladder to expel its contents in spite of the existence of some obstacle at 
or about its neck. These impediments are shown to be calculous concretions, 
enlargement of the prostate gland, stricture of the urethra, or polypi. These 
anatomical appearances are explained in the text; and, in addition, the author 
describes the operations for sounding, for the evacuation of the bladder by the 
use of the catheter and by puncture. 

Plates 65 and 66 display the surgical dissection of the posterior crural region 
and the popliteal space ; representations of the upper part of the lower extrem- 
ity were given in one of the early numbers of the book. We have here a very 
accurate exposition of the anatomical peculiarities of this important surgical 
region. And, in speaking of the ordinary state of the parts, Mr. Maclise does 
not forget to lay proper stress upon anomalies of arrangement. 

The anterior crural region, the ankles, and the foot are exposed in the next 
two draAvings. 

The concluding chapter is somewhat general in its view, being devoted to 
the consideration of the vascular system as a whole. The points in it which 
are of chief interest are, the anomalous positions and arrangements of the 
heart and principal arteries, and the formation of collateral vascular communi- 
cations. These subjects are discussed with the fulness of detail and the 
philosophical spirit which Mr. Maclise's writings generally exhibit. 

As we before mentioned, this excellent treatise on surgical anatomy is now 
completed. It consists of 150 double-columned pages of comments upon 68 
colored plates. The drawings are remarkably good, much superior, we think, 
to any anatomical plates which have hitherto been published in this country. 
They are large, clear in their exposition, and admirably designed to show what 
they profess to exhibit. The comments upon them are very judicious, except- 
ing an occasional fancy flight into the regions of transcendental anatomy. 
They are, with this exception, precisely such descriptive remarks as are 
available to a surgeon, not too minute and yet sufficiently detailed, unfolding 
to his view the important features of the different regions of the body upon 
which he may be called to operate, without bewildering him by a useless, if 
not hurtful display of nervous and vascular ramifications. Mr. Maclise must 
certainly experience great satisfaction from the high commendation which his 
labors have received from our profession in his own country, and we feel con- 
fident that equal praise will be awarded to him here, by all wbo shall be so 
fortunate as to have his work in their libraries. 
No. XLV.— Jan., 1852. 13 



180 



BihliograpUical Notices. 



[Jan. 



We would not conclude our remarks upon ttiis volume witliout acknowledging 
our sense of indebtedness to Messrs. Blanchard & Lea for the handsome 
manner in which it has been republished. The paper, the printing, the draw- 
ings, the binding, are all excellent. We hope, sincerely, that it will find 
such appreciation that the publishers shall be thereby induced to issue all 
their succeeding works in the same admirable and readable guise. 

F. W. S. 



Art. XVir. — Elements of Physiology, including Physiological Anatomy. By 
William B. Carpenter, M. I),, F. E. S., F. G. S., &c. &c. Second Ameri- 
can, from a new and revised London edition ; with one hundred and ninety 
illustrations. 8vo. pp. 566 : Philadelphia, Blanchard & Lea, 1851. 

The present work of Dr. Carpenter is one well adapted to fulfil the leading 
object of an elementary text-book — to furnish to the student a general, but at 
the same time clear and accurate outline of " those principles of physiology 
which are based on the broadest and most satisfactory foundation, and to in- 
dicate to him "the mode in which those principles are applied to the explana- 
tion of the phenomena presented by the living actions of the human body.'' 
In this manner preparing the way for " that more detailed study of the latter, 
which becomes necessary when physiology is pursued, as it ought to be, in 
connection with the changes produced in the living body by morbific and re- 
medial agents, and is thus taken as a guide in the study of the causes, preven- 
tion, and treatment of disease — which should be the primary object of attention 
with every one who undertakes the practice of his profession.^' 

The work is well and accurately prepared, presenting a faithful and intelli- 
gible outline of the science of physiology, according to the present state of our 
knowledge in respect to it. 

The edition from which the one before us is printed, has been carefully re- 
vised by the author ; such statements as the advance of science has shown to 
be doubtful or erroneous have been omitted or corrected, and a considerable 
amount of new matter has been introduced ; of the first, eleventh, and twelfth 
chapters, especially, a considerable portion has been entirely rewritten. 

The first chapter embraces an exposition of the author's views of the correla- 
tion of the vital and physical forces. As we believe these views to be most 
important, tending, as they do, much to the simplification of physiology, and, 
in their further development and extension, to the improvement of pathology 
and therapeutics, we present here their general summary as drawn up by 
Dr. Carpenter. 

" We only know of life as exhibited by an organized structure, when sub- 
jected to the operation of certain ybrces which call it into activity; and we only 
know of vitality, or the state or endowment of the being which exhibits that 
action, as conjoined with that particular aggregation and composition which 
we term organization. We have seen that the act of organization, and the con- 
sequent development of peculiar properties in the tissues which are produced 
by it, can only be attributed to the vital force of a pre-existing organism ; and 
hence it is, that whilst the operation of physical forces upon an organized body 
gives rise to vital phenomena, no such phenomena can be manifested as the 
result of their action upon any kind of inorganic matter. It is, in fact, the 
specialty of the material instrument thus furnishing the medium of the change 
in their modus operandi, which establishes, and must ever maintain, a well 
marked boundary line between the physical and the vital forces. According 
to the views here propounded, the vital force is as difi'erent from heat or elec- 
tricity, as they are from each other; but just as heat, acting under certain 
peculiar conditions, is capable of transformation into electricity, whilst elec- 
tricity is capable, under certain other conditions, of being metamorphosed into 
heat, so may either of these forces, acting under conditions which an organized 
fabric alone can supply, be converted into vital force, whilst, in their turn, they 
may be generated by vital force. 



1852.] 



Carpenter's Elements of Physiology. 



181 



" Starting, then, with the abstract notion of one general force, we might say 
that this power, operating through inorganic matter, manifests itself in those 
phenomena which we call electrical, raagnetical, chemical, thermical, optical, 
or mechanical; the agents immediately concerned in these being so connected 
by the relation of reciprocal agency, or correlation, that we must regard them 
as fundamentally the same. But the very same force or power, when directed 
through organized structures, effects the operation of growth, development, 
metamorphosis, and the like ; and is further transformed, through the instru- 
mentality of the structures thus generated, into nervous agency and muscular 
power. If we only knew of heat, for example, as it acts upon the organized 
creation, the peculiarities of its operation upon inorganic matter would seem 
no less strange to the physiologist than the effects here attributed to it may 
appear to those who are only accustomed to contemplate the physical phe- 
nomena to which it gives rise. Of the existence of force or power, we can give 
no other account than by referring it, as we are led by our own consciousness 
to do, to the exertion of a will; and this unity among the forces of nature is 
the strongest possible indication of the unity of the will of which they are the 
expressions. And further, the constancy of the actions which result from them, 
when the conditions are the same — that is, their conformity to a fixed plan, or, 
in the language commonly employed, their subordination to laws, indicates the 
constancy and unchangeableness of the divine will, as well as the infinity of 
that wisdom by which the plan was at first arranged with such perfection, as 
to require no departure from it, in order to produce the most complete harmony 
in its results. 

" So, also, if we endeavour to assign a cause for the existence of a cell germ, 
we are led, at first, to fix upon the vital operations of the parental organism by 
which it was produced; and for these we can assign no other cause than the 
peculiar endowments of its original germ, brought into activity by the forces 
which have operated upon it. Thus, we are obliged to go backwards in idea 
from one generation to another, and when, at last, brought to a stand )jy the 
origin of the race, we are obliged to rest in the Divine will as the source of 
those wonderful properties, by which the first germ developed the first organism 
of that race, from materials previously unorganized, this organism producing a 
second germ, the second germ a second organism, and so on without limit, by 
the uniform repetition of the same processes. Yet we are not to suppose that 
the continuation of the race is really in any way less dependent upon the will 
of the Creator, than the origin of it. For whilst science leads us to discard the 
idea that the Deity is continually interfering to change the working of the sys- 
tem he has made, since it everywhere presents us with the idea of uniformity 
in the plan, and of constancy in the execution of it, it equally discourages the 
notion entertained by some, that the creation of matter endowed with certain 
properties, and therefore subject to certain actions, was the f nal act of the 
Deity, as far as the present system of things is concerned, instead of being the 
mere commencement of his operations. If it be admitted that matter owes its 
origin and properties to the Deity, or, in other words, that its first existence was but 
an expression of the Divine will, what is its continued existence but a continued 
operation of the same will? To suppose that it could continue to exist, and to 
perform its various actions, by itself, is at once to assume the property of self- 
existence, as belonging to matter, and thus to do away with the necessit}^ of a 
Creator altogether, a conclusion to which it may be safely affirmed that no ordi- 
narily constituted man can arrive, who reasons upon the indications of niiud 
in the phenomena of nature, in the same way as he does in regard to the crea^- 
tions of human art." 

Doctrines precisely similar to those, the summary of which is given in the 
foregoing paragraphs, have been taught for several years back by l3r. Jackson, 
in his lectures on the Institutes of Medicine, in the University of Pennsylvania, 
and were announced in a discourse published as early as 1837.. The proposition 
was then laid down, that the same causes and actions " which in inorganic bodies 
constitute physics, in inorganic bodies constitute physiology, or, as it may be 
more aptly termed, organic physics.'' 

To do justice to the views that have been maintained by Dr. Jackson in his 



182 



BibUograpMcal Notices. 



[Jan. 



lectures for the last eight years, we present the following extracts from a dis- 
course recently published by that gentleman: — 

" The force presiding over the production of plastic matter is the same as 
the chemical force of organic bodies, and the primary and common organic 
form, a cell, may, as Mulder states, be the inevitable consequence of the special 
material. But whence come the special organic forms, so numerous, it may be 
said endless ; so diversified and complex, yet always the same, and constructed 
on a plan perfect of its kind, and expressive of an ideal conception of the 
highest intelligence ? Is it possible to regard the organic forms of living beings, 
bearing the impress of ideas that could originate only in the profoundest know- 
ledge, and the very supremacy of wisdom, as proceeding from a force identical 
with chemical or physical forces, or any mere material force, or a necessary 
result of any material condition ? 

" Employing the term force in its philosophical sense, as the expression of 
an unknown cause, I have been accustomed to ascribe this class of phenomena 
as exclusively belonging to organic force, or the radical force of life. 

" The special character of organic or radical force of life, if this view be cor- 
rect, is modality, or the power of creating organic forms, the instruments and 
mechanisms of life. It possesses none of the attributes of the physical forces 
in its actions and influences. It has no identity with them ; yet there is un- 
doubted correlation. 

" Forms are immediately connected with matter, and organic forms with 
special protoplasms. These organizable materials are the product of chemical 
actions and play of chemical force, while this special direction of chemical force 
is depending on a definite temperature 98° to 100° in warm-blooded animals. 

"Again: organic matter is always the product of living beings ; is prepared 
in organic or life instruments, under the chemical force which can accomplish 
those combinations only under the condition of a living organ endowed with 
organic force. 

" The correlation is evident. There exists a chain of sequences, each one of 
which is an indispensable link, necessary to the creation, in a material form, 
of an ideal type. But correlation and intimate dependency do not constitute 
identity of nature. A clear distinction is apparent between the force that pre- 
pares, by a chemical action, the material for constructing an organ or instru- 
ment, and the force that forms an ideal plan of the instrument or organ, and 
constructs it of this material. 

"Examples illustrating this proposition are furnished by the eye — an optical 
instrument; by the ear — an acoustic instrument; by the heart — an hydraulic 
engine; and the lungs, a pneumatic apparatus. Each of these is formed of 
numerous pieces, adjusted with the nicest precision, and adapted to perform a 
particular part necessary to the completion and working of the instrument. 
The material of which each separate piece is formed is special to that piece, 
yet has been derived from one common source, the blood, in which it did not 
exist. The organization or structure and the form are totally different in each, 
even at the point where they are in direct conjunction, and by no other struc- 
ture or form could the especial organ or instrument be constructed. Complex 
results like these are not compatible with mere nutrition or growth." 

" The phenomena unquestionably the most characteristic of organic nature, 
are, the perpetual production of special organic matters, and repetitions, in suc- 
cessive generations, of the same typical forms, infinite in number and variety, 
expressed in the organization of living beings. Organic forms have continued 
through all time unchanged, invariable under the same circumstances, the off- 
spring being the representatives of the parents. 

** These forms, evolved from a formless organic matter, were the first manifest- 
ations of the Divine Thought in the creation of the organic world. They ema- 
nated from the creative power of the Supreme Intelligence, moulding in mate- 
rial forms the ideal of the Eternal Mind. 

" The present repeats the past. Organic forms proceed from formless plastic 
matters now, as at the beginning. Creation has never ceased ; creative power 
has never intermitted its activity ; organic forms are being incessantly evoked 
from a chaos of formless organic matter. 



1852.] 



Carpenter's Elements of Physiology. 



183 



"The most striking and familiar feature distinguishing organic forms, at once 
mysterious and indefinable, is the permanency of the created form, while the 
material expressing that form is the most unstable and transitory of sub- 
stances. 

" The form is maintained undisturbed amidst incessant vortices of atoms and 
endless storms of molecular actions, by which the materials of organic forms 
are chemically decomposed and recomposed. Two forces are in incessant an- 
tagonism; the organic typical or modal force, creative and preservative of the 
organic form, and the chemical forces of the material molecules, that keep the 
substance of the form in endless change. The force that thus controls mole- 
cular actions, and impels them to evolve from matter typical organic forms, the 
ideal of creative intelligence, is an exclusive attribute of organic nature. It 
is transmitted from generation to generation, and is the endowment of the 
germ. Germ force, and organic force, are identical. 

"Of all the mysteries in the midst of which, unconscious of them, we exist, 
none are more profound, deep, and inscrutable, than the mysterious attribute 
of the germ, constituting its proper force. 

" The gerna is the sole link existing between generation and generation, 
from the first dawn of creation to the present. It imparts perpetuity and unity 
to the families and races of the organic world. For while individuals perish 
and die, the race continues unbroken in a single and endless existence. The 
organic characteristics that separate and distinguish the class, the order, the 
genus, the species and varieties of all organic beings, have descended un- 
changed through countless generations. And yet further, from parents are 
conveyed to offspring the individual peculiarities of constitution, teniperament, 
resemblance, mental faculties, and disposition, hereditary diseases, and exist- 
ing taints or vices of blood. Through what medium is effected this transmis- 
sion of various organic influences ? It can be no other than the germ, for it is 
the only existing point of connection. Are we not presented, in this series of 
extraordinary yet incontestable facts, the demonstration that in the germ the 
forces of organic nature are concenterd? 

" When we reflect on what is known of the germ, the mind is bewildered 
and amazed in the contemplation of such extraordinary phenomena. The germ 
is a microscopic speck, requiring a magnifying power of some four hundred 
diameters to bring it within the range of distinct vision. Though of this 
minute size, it is a complex product, resulting from the union of a male and 
female generative principle, which, as demonstrated by Mr. Newport's experi- 
ments, may result from their contact for two seconds only, and at most of five 
or six.'' 

" The initial phenomena of life — production of organizable matter and or- 
ganic forms — are reiterated throughout existence. They constitute alone the 
sole phenomena that can, wdth correct logic, be termed life, or organic actions. 
In every tissue, while its vital activity is in operation, its special organizable 
material and its special form are incessantly being produced. 

" The force that presides over and directs these actions preserves the inte- 
grity of the organs and their functions during life. It opposes a resistance 
to all disturbing agents, successfully, if they be not armed with too great 
power, or itself has not been enfeebled by accidental circumstances, which con- 
stitute predisposition to disease : and when morbific causes have been removed, 
or their actions have ceased, it restores the organs to a natural condition. The 
organic germ, or formative force, shows itself to be what has been recognized 
as the ' vis medicatrix naturae,' or known by other similar designations. This 
force must be the reliance of the physician for the successful treatment of dis- 
ease. It is the principal business of the practitioner to remove the impediments 
that interfere with, disturb, or suspend the conditions or laws of life action, the 
recuperative laws of the economy, and thus enable the organic force to re-estab- 
lish the organic or vital actions in their normal state. 

" From this analysis of organic phenomena, it is impossible to refuse the 
inference, that typical forms are the most prominent feature of organic nature. 
Phenomena so constant, diverse yet invariable, the mind, by its instinctive 
proofs of causation, assigns to the operation of an unknown cause, a force, 



184 



BihUograpliical Notices. 



[Jan. 



precisely as by causation it refers the phenomena of caloric, electricity, gravity, 
and magnetism, to unknown causes or forces. 

" Taking this view of the subject, I must dissent from the opinion of Dr. 
Carpenter, who regards organic forces as identical with the physical forces. 
No one can deny their correlation: but no phenomena of the physical forces 
have analogy or resemblance to the persistent maintenance of tj^pical forms 
amidst the eternal commotion and vortices of the atoms of organic matter in its 
eternal circle of decomposition and recombination, the constant phenomena of 
organic actions. 

" I feel compelled, from the preceding considerations, to assert the existence 
of a peculiar organic or vital force, exclusively manifested in organic or living 
beings, the dominant principle of organic or vital actions, and the generator of 
typical organic forms. 

"The second class of phenomena that have been regarded as organic is en- 
tirely different in nature and character. It is the nervous force, or excito-motor 
force, the direct excitant of muscular contractility. It has acquired this 
distinction of a vital force from the necessity of the mechanical power of mus- 
cular action in the respiration of the warm-blooded vertebrata, breathing with 
lungs. 

" The action of the respiratory muscles is determined by the respiratory 
ganglia of the medulla oblongata. The phenomena are dynamic, and not or- 
ganic ; the force producing it has the strongest analogy to electricity, though, 
as yet, their identity has not been completely established. 

" That this force is not an organic force is clearly apparent. It is limited to 
a part of living beings. It has no existence in the vegetable kingdom, and is 
found necessary to sustain, and that only indirectly, the organic or vital 
actions in the warm-blooded vertebrata alone. It is a function of an apparatus, 
and not a radical force or principle; and that apparatus, the respiratory gan- 
glia seated in the medulla oblongata, becomes a vital centre, the pivot on 
which turns the machinery of life in those animals and man, solely from the 
necessity of oxygen as a chemical agent in the evolution of animal heat, and in 
effecting changes in organic matter. 

" The nervous force is so closely allied to the physical forces that it must be 
classed with them. Between the phenomena of sensibility, consciousness, will, 
the intellectual and moral faculties, and those of nervous motor force, of the 
physical and organic forces, there is an entire absence of similitude or analogy; 
they are so wholly distinct and dissimilar, it is impossible to conceive the 
remotest approach to identity. 

" The nervous force belongs to dynamics, and is the spring of animal me- 
chanic power ; it is the source of the automatic or involuntary actions of the 
animal economy, presiding over its material conservation. Mind is the essence 
of man. Through it he possesses a spiritual nature, and an existence in the 
ideal; it disunites him from matter, and associates him with the immaterial; 
it enables him to comprehend, in thought, the existence of God the Supreme 
Creator of the universe ; it endows him with the capacity of conceiving the 
divine idea in the plan of the universe, and of the laws of nature, the instru- 
ments by which that plan is perfected, by contemplating and studying the 
phenomena of which it becomes conscious through its perceptive faculties. 
Possessing this knowledge, man subjecting nature to his uses, and compelling 
her laws to execute his designs, has created a social, moral, political, and 
physical world; a world of arts, sciences, and philosophy, in the midst of 
which he dwells, and over which he has unbounded sway. 

" Attributes thus super-eminent, and relations thus superlative, can have no 
identity with matter or physical forces. These strongly attest that mind, 
capable of penetrating to the Divine thought, and thereby acquiring, to a cer- 
tain extent, a creative power over the material world, must partake, in an 
imperfect manner, of the nature of the Supreme Intelligence. 

" The distinction between nervous force and mind is as marked as that of 
the steam force of the locomotive, impelling its movements, and the engineer, 
who controls and guides \V 

By comparing this extract from the recent published lecture of Professor 



1852.] 



Walshe on Diseases of the Lungs and Heart. 



185 



Jackson, with that previously ^iven from the work of Dr. Carpenter, the reader 
will perceive the close resemblance — we had almost said identity — for the dif- 
ference, if any, is rather in words than in ideas — of the views entertained by 
these two gentlemen in reference to the correlation existing between the vital 
and physical forces. Similar views are beginning to be entertained by several 
of the distinguished physiologists of continental Europe. As early as 1845, 
the correlation and identity of physical and vital forces was promulgated in 
Germany by Dr. Mayer, of Heilbronn ; and Professor Grove in the second edi- 
tion of his " Correlation of Forces,^' published in 1850, makes the following 
remarks : "I believe that the same principles and mode of reasoning as have 
been adopted in this essay, might be applied to the organic as well as to the 
inorganic world, and that muscular force, animal and vegetable heat, &c., 
might, and at some time will, be shown to have similar definite correlations.''^ 

The adoption of similar views on this important subject by individuals un- 
connected with each other, and evidently unacquainted with the results arrived 
at by the others, is a strong prima facie evidence of the foundation of those 
views in truth. D. F. C. 



Art. XVIII. — A Practical Treatise on the Diseases of the Lungs and Heart, includ- 
ing the Principles of Physical Diagnosis. By Walter Hayle Walshe, M. D. 
12mo. pp. 512 : Philadelphia, Blanchard & Lea, 1851. 

Eight years ago, Dr. Walshe's work on " The Physical Diagnosis of Diseases 
of the Lungs'' was noticed in this Journal. The volume before us contains, 
in its first part, an enlarged and amended edition of the earlier work; a com- 
plete system of physical diagnosis of diseases of the heart, and a systematic 
description of pulmonary and cardiac affections, follow, and form two-thirds of 
the entire treatise. The number of works devoted to the same subjects which 
have been published of late, render unnecessary, and unprofitable, a complete 
analysis of the one before us, and we shall therefore confine the reader's atten- 
tion to those points on which it may be interesting to know the results of Dr. 
Walshe's observation, and the grounds upon which the opinions of so accom- 
plished a diagnostician rest. These circumstances will account for the some- 
what desultory and disjointed character of the remarks which it is proposed to 
make. 

The difficulty of making accurate circular measurements of the chest must 
have been felt by every one in cases where the patient is unable to quit the 
recumbent posture. It may be entirely removed by the expedient which Dr. 
Hare suggested — 

" That of joining together two graduated tapes at the commencement of their 
scales, and fixing them, as the patient reclines, at their line of union to the 
spine : each side of the chest has thus its separate measure." 

The author does not approve of the percussor, in the form of a hammer, the 
invention of Dr. Winterich of Wurzburg, which many continental physicians 
employ, and which has been recommended in England by Dr. Hughes Bennet. 
During the last winter, we had repeated opportunities of witnessing its employ- 
ment by Skoda, and other teachers in Vienna, and can testify to its great supe- 
riority over the fingers, used for the same purpose, especially for the instruction 
of large classes in hospitals. The sounds which the plexiraeter emits, when 
struck by this instrument, are incomparably louder and more distinct than any 
which the hand alone can elicit, and we are persuaded that it will be found a 
valuable aid to all who practice percussion. 

The whole subject of percussion is elaborated by Dr. Walshe with a degree of 
fulness and precision which leaves nothing to be desired ; indeed, if one were 
not familiar with the wonderfully accurate results of this means of diagnosis, 
the description might be taxed with excessive minuteness. Any one who is 
disposed to distrust the mechanical processes of percussion and of auscultation, 
will find, on perusing our author's account of their uses, that they in fact tax 



186 



Bibliographical Notices. 



[Jan. 



the reasoning powers to the utmost, in arranging and comparing the pheno- 
mena revealed by them, and in drawing those precise conclusions which dis- 
tinguish this department of pathology above all others. 

The results of auscultation as a means of diagnosis are detailed at great 
length and with a surprising amount of illustrative matter. The theory of each 
several sound is also amply and perhaps too minutely discussed. We observe 
that the author still adheres to the notion that the crepitant ronchus is gene- 
rated externally to the pulmonary cells, by their unfolding during inspiration, 
and not as suggested by our countryman, Dr. Carr, of Canandaigua, N. Y., by 
the separation of the opposite and adherent surfaces of the interior of the pul- 
monary cells, during the same act. He does not furnish any grounds for his 
hypothesis which would not afford a firmer support to the other opinion. One 
might be disposed to reject the former unconditionally, were it not proved that 
the presence of air is not essential to the generation of a form of subcrepitant 
ronchus. 

Thus, in a case of phthisis, terminating in general dropsy, the author found 
" an extremely abundant subcrepitant ronchus occurring almost in puffs, in 
the entire height of the left side posteriorly. Yet, on examination after death 
of the patient, the left lung was found to be indurated and particularly dry, 
and separated from the walls of the chest, by " a quantity of fine adventitious 
cellular tissue, abundantly infiltrated with liquid.'^ This form of ronchus, which 
is described as either squashy or crackling, is not affected by coughing, and is 
usually attended by friction sounds, which circumstances serve to distinguish 
it from the true parenchymatous ronchus which it resembles. 

The article on " Modified Resonance of the Voice" contains a very elaborate 
and interesting account of the diagnostic value of this sign, with an examina- 
tion of the various hypotheses which have been framed to account for its phe- 
nomena, but without satisfactorily explaining all its peculiarities. A very 
common mistake, that of confounding the natural resonance of a shrill voice 
with oegophony, is pointed out, as well as the inanner of avoiding it. The for- 
mer exists in pleurisy, where dulness is greatest; the latter, where the stratum 
of fluid is thin ; the one, therefore, near the base of the lung, the other at its 
root. 

In the account given by our author of the mechanism of the heart's sounds, 
he labours under the difficulty felt by all writers who attempt to explain the 
action of the heart according to the theory taught by Dr. Hope, and commonly 
received in this country. As this theory denies to the auricle any share in the 
impulse which the heart makes against the ribs in many cases of hypertrophy, 
and even in health, its advocates are obliged to resort to the most extravagant 
suppositions to explain certain morbid phenomena. Having elsewhere in this 
Journal recorded the objections to this theory (see No. for July, 1846, p. 
174, &c.), which we entertain, it is unnecessary to repeat them here, only re- 
marking that the lapse of time has not diminished our confidence in their validity. 
It is because we regard the author's theory of cardiac sounds as fiir from being 
demonstrated, that we here renew our objection to the use of the terms " systolic" 
and " diastolic" when applied to cardiac murmurs. It seems to us that the 
phrases " in the first sound," "in the second sound," &c., although somewhat 
more unwieldy, are much preferable, because they merely designate the sensual 
relations, without assuming any theory of the mechanism, of the normal sounds. 
Whoever does not accept the author's theory of the murmurs will find the ac- 
companying nomenclatbire a serious obstacle to applying his explanation to the 
phenomena presented by an obscure case of valvular disease. 

The account of diseases of the lungs and heart, contained in Part II., has 
reference chiefly to their physical signs; their general symptoms and treatment 
are very summarily presented. To have done more would have been beside 
the author's purpose, and we only allude to the fact to prevent disappointment on 
the part of those who may expect to find in the work a complete " Practice of 
Medicine" for the diseases to which it relates. 

Speaking of the prognosis in acute pleurisy. Dr. Walshe makes the following 
statement, which deserves consideration by those who regard the disease as de- 
manding bleeding, blistering, mercurials, and the whole armament of antiphlo- 
gistics. "Death is so rare a result of the disease when attacking individuals 



1852.] 



Walshe on Diseases of the Lungs and Heart. 



187 



free from orj^anic affections, that I have neither myself (and I have carefully 
attended to the point since my attention was first drawn to it, years ago, by M. 
Louis) lost a patient from pure primary idiopatliic pleurisy, with or without 
effusion, nor known of an occurrence of the kind in the practice of others." 

In some cases, where neither the sputa nor the ronchi indicate the existence 
of pneumonia, or, at least, not at the moment of examination, the ratio of the 
pulse to the respiration is a valuable sign ; for an amount of pneumonic solid- 
ification capable of suggesting doubt, Avill make the respiration half or even 
three-fourths as frequent as the pulse, but such a perversion has never been 
met with in pleurisy by Dr. Walshe. 

The author insists upon the use of blisters to remove pleuritic effusions which 
continue after the subsidence of fever, but his precept for employing them is 
all important. Allowed to produce copious suppuration, as they sometimes 
are, they tend to light up fever anew, but when " made of large size, applied in 
different situations, not kept on longer than is just sufiicient to produce vesica- 
tion, and every means used to secure the healing of the blistered surface," they 
unquestionably hasten the absorption of the effused fluid in a very remarkable 
manner. They are not less useful under these circumstances than they are 
mischievous during the febrile stage of the attack. 

Although Dr. Walshe does not eulogize, as much as some late writers have done, 
the operation of paracentesis in cases of stationary or increasing effusion in the 
pleura, he nevertheless considers that its results entitle it "to being numbered 
among the most valuable gifts of surgery." Ilis qualified eulogy of this remedy 
arises from the circumstance that, in most reports of its success, all sorts of cases, 
simple and complicated, are " clubbed together." We would observe, however, 
that this imperfect classification rather tends to derogate from the value of the 
operation than to exaggerate it. Unquestionably, had all the cases been in- 
stances of simple chronic pleurisy, the results would have been more favourable 
than they are actually represented to be. As our author observes, the quality of 
the effusion, and the state of the conservative functions, influence very strongly 
the results of the operation. He blames the delay which so often renders the 
operation inadmissible, or greatly diminishes the chances of its success, and 
concludes that " the fitting time for operation has come when a tendency, insu- 
perable by medical means, exists either to increase or to non-absorption of the 
fluid." It is unnecessary to follow him in the description of the operation. 
He advises the closure of the wound after the first evacuation of the fluid. 

The chapter on Pneumonia is remarkably full and satisfactory, as might be 
expected when so capable an author describes a disease which has been so 
thoroughly investigated. A statement of much importance is that, according to 
the author's experience, " if the expectoration in pneumonia be actually bloody, 
the pneumonia is tuberculous." In the treatment of the disease, he considers 
that they are no barriers to venesection provided the type of the attack is sthenic. 
Neither age, pregnancy, nor menstruation, is a contra-indication, nor awy period 
of the disease too late for blood-letting, " provided the indication be thoroughly 
established on general principles." The author seldom bleeds more than twice, 
taking sixteen ounces the first, and some ten or twelve the second time. Of 
tartarized antimony with cupping, as a substitute for general bleeding, he 
would choose the former, but prefers both. He does not find any evidence that 
toleration is an index of the usefulness of antimony. The dose, at first, should be 
" half a grain, combined with dilute hydrocyanic acid, paregoric, and tincture 
of orange peel, every hour for the first three or four hours, and then increased, 
at intervals of two hours, to one grain ; in the course of twelve hours, the quan- 
tity may be raised to two grains, and its repetition made less frequent, say every 
fourth hour." Mercurials are, in our author^s opinion, desirable in those cases 
only where antimony is inadmissible. Blisters he approves of, in the more 
advanced periods of the affection, to relieve pain and dyspnoea. 

The chapter on " Hemorrhage and IlEcmoptysis" contains some valuable 
evidence on the question of the connection of hgemoptysis with tubercle in adults. 
We have not room to present even an epitome of these statements, but especially 
desire to direct attention to them, as proving most clearly "the vast frequency 
with which haemoptysis is in some manner or other attendant on tuberculous 



188 



BihliograpMcai lYotices. 



[Jan. 



disease." Among the means of arresting excessive pulmonary hemorrhage, the 
author speaks of the cautious application of ice in bags to the spine, and over 
the heart, as often arresting instantaneously the flow of blood. 

Phthisis is very fully and clearly discussed by Dr. Walshe. " The physical signs 
of arrested phthisis," he remarks, "have never yet been systematically exam- 
ined." No wonder, indeed; for how few, alas ! are the cases which can be pre- 
sented to illustrate this state, which but for recent experience one might, without 
much violence to truth, rank among things chimerical. The following are among 
the phenomena of this condition, which the author has observed. In one case 
notable depression, supra and infra-clavicular; imperfect expansion; very 
weak, harsh respiration ; dulness under percussion ; exaggerated fremitus, and 
strong vocal resonance ; a deep, creaking sound on respiration. Respiration of a 
laboured, jerking rhythm ; hollow, dry, cavernous respiration, variously combined 
with the signs already enumerated, were observed in cases, which, at an earlier 
period, had presented all the evidences of tubercular softening in the lungs. The 
diagnosis of this most common and most fatal of all non-malignant chronic dis- 
eases is so interesting and important, that we offer no apology for quoting at 
length the summary which our author gives of its elements. 

*' A young adult, who has had an obstinate cough, which commenced with- 
out coryza, and without any very obvious cause, a cough at first dry and subse- 
quently attended for a time with watery or mucilaginous-looking expectoration, 
and who has wandering pains about the chest, and loses flesh even slightly, is 
in all probability phthisical. (6) If there be haemoptysis to the amount of a 
drachm even, the diagnosis becomes, if the patient be a male and positively 
free from aneurism and mitral disease, almost positive, (c) If, in addition, there 
be slight dulness under percussion at one apex, with jerking or divided and 
harsh respiration, while the resonance at the sternal notch is natural, the diag- 
nosis of the first stage of phthisis becomes next to absolutely certain, (d) But 
not absolutely certain: for I have known every one of the conditions in a, h, and 
c, exist (except haemoptysis, the deficiency of which was purely accidental), 
when one apex was infiltrated with encephaloid cancer, and no cancer has been 
discovered elsewhere to suggest to the physician its presence in the lung, (e) 
If there be cough, such as described, and permanent weakness and hoarseness 
of the voice, the chances are very strong (provided he be non-syphilitic) that 
the patient is phthisical. (/) If decidedly harsh repiration exist at the left 
apex or at the right apex behind, if the rhythm of the act be such as I have 
called cogged-ioheel, and there be dulness, so slight even as to require the dyna- 
mic test for its discovery, there can be little doubt of the existence of phthisis. 
[g] If with the same combination of circumstances deep inspiration evokes a 
few clicks of dry crackling ronchus, the diagnosis of phthisis, so far as I have 
observed, is absolutely certain, [h] If these clicks on subsequent examina- 
tion grow more liquid, the transition from the first to the second stage may 
be positively announced, [i) If there be slight flattening under one clavicle, 
with deficiency of expansion-movement, harsh respiration, and slight dulness 
under percussion, without the local or general symptoms of phthisis, the first 
stage of tuberculization cannot be diagnosticated with any surety, unless there 
be incipient signs at the other apex also: the conditions in question limited to 
one side might depend on chronic pneumonia, or on thick induration-matter in 
the pleura, {k) The existence of limited, though marked, dulness under one 
clavicle, with bronchial respiration and pectoriloquy, so powerful as to be pain- 
ful to the ear, the other apex giving natural results, will not justify the diagnosis 
of phthisis. I have known this combination when the apex of the lung was of 
model health, and a fibrous mass, the size of a walnut, lay between the two 
laminae of the pleura. I would even go further, and say that the combination 
in question is rather hostile than otherwise to the admission of phthisis ; as, 
had tuberculous excavation formed at one side, the other lung would, in infinite 
probability, have been affected in an earlier stage. [1] Pneumonia, limited to 
the supra and infra-clavicular region on one side, and not extending backwards, 
is commonly, but not always, tuberculous, [m] Subcrepitant ronchus, limited 
to one base posteriorly, is not, as has been said, peculiar to tubercle ; it may 
exist in emphysema and in mitral diseases, [n) Chronic peritonitis, in a per- 



1852.] 



Walshe on Diseases of the Luncjs and Heart. 



189 



son aged more than fifteen years, provided cancer can be excluded, involves a» 
a necessity the existence of tubercles in the lungs. To this law of Louis's, it 
is necessary to add the qualification, provided Bright's disease be also absent, 
(o) Pleurisy with effusion, which runs a chronic course in spite of ordinary treat- 
ment, is, in the majority of cases, tuberculous or cancerous ; the character of 
the symptoms, previously to the pleurisy, will generally decide between the 
two. [p) Double pleurisy, with effusion, is not, as has been said, significant of 
tubercle ; for it may depend on Bright's disease. If the latter disease can be 
excluded, carcinoma and pyohsemia remain as other possible causes, [q] If a 
young adult, free from dysentery, and who has not resided in tropical climates, 
suffers from obstinate diarrhoea, which goes on month after month, with slight 
remissions and intermissions, even though there be no cough, he is in most 
strong probability phthisical. If physical signs, to the slightest amount, exist 
at either apex, he is, almost to absolute certainty, phthisical, (r) If a young 
adult, free from secondary syphilis and spermatorrhoea, and not dissolute in his 
habits, steadily lose weight, without clear cause, he is in all probability phthi- 
sical, even though no subjective chest-symptoms exist, [s) But he is not by 
any means certainly so ; for he may have latent cancer in some unimportant 
organ, or he may have chronic pneumonia, {t) Nay, more, he may steadily lose 
weight, have dry cough, occasional diarrhoea, and night-sweats, and present dul- 
ness under percussion, and bronchial respiration under both clavicles, and yet be 
non-phthisical. I have known all this occur in cases, both when the lungs were 
infiltrated superiorly with primary encephaloid cancer, and when they contained 
secondary nodules of the same kind, [u) Failure of weight becomes less valu- 
able as a sign of phthisis, the longer the thirtieth year has been passed, [v) 
The discovery of cardiac disease with marked symptoms deposes against, but 
does not exclude, the existence of active tuberculization, [tv) The existence of 
cancer in any organ is unfavourable to the presence of tuberculous disease; but 
tubercle and cancer may co-exist even in the same lung.^' 

It is cheering to every humane physician that one so capable and impartial 
as Dr. Walshe should take a view of the tendencies of consumption, very dif- 
ferent from what has been almost universally entertained by writers upon this 
fell disease. He believes that the treatment of the phthisical may confidently 
aim, either at producing slight improvement, at totally removing the subjective 
symptoms, and either ameliorating or rendering quiescent the physical signs, 
while the general health, weight, and vigour, improve to such an extent that 
the patient may believe himself cured, and the physician might also think so, 
did not passive physical changes remain. Our readers are probably familiar 
with the statistical results of the treatment by cod-liver oil, in the London 
Consumption Hospital, which our author has already published. We now pre- 
sent the conclusions to which a longer and more extensive use of this agent has 
led him. 

"I began to employ the oil at the Consumption and University College Hos- 
pitals seven years ago, urged to the step by the strong advocacy of Dr. Hughes 
Bennett, and took an early opportunity of testifying to its remarkable powers 
in tuberculous and other scrofulous diseases.* The conclusions at which I 
have arrived concerning its use in phthisis are as follows : 1. That it more 
rapidly and effectually induces improvement in the general and local symptoms 
than any other known agent. 2. That its power of curing the disease is unde- 
termined ; — I mean here, by ' curing' the disease, its power of causing, along 
with suspension of progress, such change in the organism generall3^ as shall 
render the lungs less prone to subsequent outbreak of tubercles, than after 
suspension occurring under other agencies.f 3. That the mean amount of 

* Nature and treatment of cancer, p. 202, 1846, 

■j- That such cures really occur in rare instances (and they are as perfect as in any 
other organic disease, when they do occur) is indubitable. It has been the vanity of late 
years to deny this absolutely, because a scientific (or pseudo-scientific ?) explanation of 
the fact cannot be found. I am not one of those who refuse to accept the evidence of my 
senses, because Jam unable to comprehend what they teach me, and in this manner echo 
the sentiments of the physician in a recent French tale, speaking of a phthisical reco- 



190 



BihliograpMcal Notices. 



[Jan. 



permanency of the good effects of the oil is undetermined. 4. That it relative- 
ly produces more marked effects in the third, than in the previous stages. 
Opinions the most diverse have been held on this point. M. Taufflied* taught 
that it had little or no effect on phthisis, if at all advanced; M. Pereyraf reduced 
tlie size of cavities in a few weeks by its administration. 5. That it increases 
weight in favourable cases with singular speed, and out of all proportion with 
the actual quantity taken ; — that hence it must in some unknown way save 
waste, and render food more readily assimilable. 6. That it sometimes fails to 
increase weight. 7. That in the great majority of cases where it fails to increase 
weight, it does little good in other ways. 8. That it does not relieve dyspnoea out 
of proportion with other symptoms. 9. That the effects traceable to the oil in 
the most favourable cases are : increase of weight, suspension of colliquative 
sweats, improved appetite, diminished cough and expectoration, cessation of 
sickness with cough, and gradual disappearance of active physical signs. 10^ 
That in some cases it cannot be taken either because it disagrees with the stomach, 
impairing the appetite (without itself obviously nourishing), and causing nau- 
sea, or because it produces diarrhoea. 11. That in the former case it may be 
made palatable by association with a mineral acid ; and in the latter prevented 
from affecting the bowels by combination with astringents. 12. That intra-tho- 
racic inflammations and haamoptysis are contra-indications to its use, but only 
temporarily so. I have repeatedly given the oil within a day or two of the 
cessation of haamoptysis without any return taking place. 13. Diarrhoea, if de- 
pending on chronic peritonitis, or secretive change, or small ulcerations in the 
ileum, is no contra-indication to the use of the oil ; even the profuse diarrhoea 
caused by extensive ulceration of the large bowel is not made worse by it. 
14. That the good effects of the oil are ccsteris paribus directly as the youth of 
those using it, — a singular fact, which probably may one day (when the tex- 
tural peculiarities of youth and age are better understood) aid in giving a clue 
to its mode of action. 

"Of the three kinds of oil — the brown, light brown, and pale — the brown, I 
believe, as a matter of actual experience, to be the most efficacious. J But though 
taken greedily by infants, it is more distasteful than the pale to the adult palate, 
and hence in grown up persons I have been forced to use the latter, less active 
kind (in fact, gild the pill), in order to ensure oil being swallowed at all. 
Chemists give no positive answer to the question, on what depends the efficacy 
of the drug ? Its influence on the composition of the blood is yet undetermined. 
A single analysis by Simon shows a state of hyperinosis, combined with a great 
excess of albumen, may follow on its use ; the solid constituents were in large 
amount. The patient had been bled repeatedly for hgemoptysis. The iodine 
of the oil, its phosphorus, butyric acid, gaduine, biliary material, and its mere 
fatty matter have been severally accorded the chief part in the beneficial results. 
The discussions on this point do little more than exhibit the existing poverty 
of our knowledge of the intimate action of remedies. On the other hand, the 
established efficacy of the oil — a substance of which d priori Yiews would scarce- 
ly have admitted the possible retention by the phthisical stomach — is another 
of the conquests of experime?ital therapeutics.^ 

" The dose of the oil at the outset should never exceed (often fall short of) a 
drachm twice daily ; it may be taken in water, milk, orange wine, or any aroma- 
tic water agreeable to the patient. The dose may be gradually raised to half an 
ounce, twice, or at most thrice, in the twenty-four hours. I have never seen 

very: — .... " ces miracles de guerison, aux quels la Science ne croit pas, faute de les 
comprendre, et devant ks quels je me prosterne, en priant la bonne et sage Nature d'enetremoins 
avare." — Pierre, par Madame Reyband. 

* Gaz. Med. de Paris, Nov., 1839. 

f Du Traitement de la Phthisie. Bordeaux, 1843. 

J On the properties of these varieties of oil, see De Jongli on Cod-liver Oil, by Carey, 
Lond., 1849. 

§ As is well known, cod-liver oil has been a household reuiedy from time immemo- 
rial in the north of Europe. 



1852.] 



Beck's Materia Medlca and Therapeutics. 



191 



any good, and often observed ill, effects follow the attempt to pour in large 
quantities." 

Diseases of the heart are very thoroughly discussed by our author. We have 
marked many passages for comment or approval, but our limited space prevents 
even an enumeration of them. One, however, we cannot refrain from noticing, 
since it relates to a very common and pernicious error, the habit, namely, of 
prescribing active treatment in hypertrophy of the heart. The author declares 
that he has "never known the cure of indubitable hypertrophy, proved by phy- 
sical signs." The usual sedative palliatives are approved of by him, with an 
especial commendation of aconite, which he gives in the form of alcoholic ex- 
tract of the root, in doses of one-eighth of a grain. 

On the whole, there is a great deal of valuable information in this treatise, 
which is not contained in any previous one, upon the same subject, and which, 
considering its quality, and the source it proceeds from, cannot fail to become 
a permanent addition to the pathology and treatment of thoracic diseases. AVe 
have only to regret the extreme compression of the style of the work, which, by 
crowding too closely a number of dissimilar ideas, renders it no light matter 
to read, and, in some cases, even obscures the sense. A. S. 



Art. XIX. — Lectures on Materia Meclica and TJierapeuiics, delivered in the Col- 
lege of Physicians and Surgeons of the University of the State of New York. By 
John B. Beck, M.D., late Professor of Materia Medica and Medical Jurispru- 
dence. Prepared for the Press hy his friend, C. K. Oilman, M. D., Professor 
of Obstetrics, etc., in the College of Physicians and Surgeons, N. Y. 8vo. 
pp. 581: New York, Samuel S. and William AYood, 1851. 

As a text-book, for the use of students, we know of no treatise better, and 
very few, indeed, that are as well adapted as the one before us. It presents a 
sufficiently full digest of the present state of knowledge in reference to the 
leading articles of the materia medica, perhaps, to all the more valuable reme- 
dial agents, and an admirable, if not very full, sketch of the effects of these 
agents in their application to the management of disease ; the subjects com- 
prised under these two heads being arranged with much perspicuity, and ex- 
pounded in a concise, but, at the same time, clear and pleasing style. The 
lecturer possessed evidently a practical rather than a discursory mind, and 
was more interested in tracing the known properties and effects of the materia 
medica than in framing novel and specious theories to account for their curative 
powers ; in the language of his friend and editor, he was not a runner after 
new things; his study was much more into the indications of tr^tment, the 
circumstances modifying the operation of medicines, and those kindred topics 
which may be denominated the philosophy of materia medica. 

In the classification of remedies, adopted by Dr. Beck, his only objects, he 
states, were simplicity and convenience — medicines being arranged by him 
" according to their more prominent and acknowledged effects on the system," 
into six great classes : Evacuants, Depressants, Narcotics, Excitants, Kevul- 
sives, Alteratives. 

The first class is divided into nine orders : Emetics, Cathartics, Anthelmin- 
tics, Sialagogues, Diaphoretics, Diuretics, Expectorants, Emmenagogues, Par- 
turients. 

Of the second class there are three orders : Sedatives, Refrigerants, Demul- 
cents. 

Narcotics are not divided. 

Of Excitants there are four orders: Stimulants, Nervines or Antispasmodics, 
Tonics and Astringents. 

Of Revulsives two, Internal and External ; and of Alteratives two, Vital and 
Chemical. 

In treating, first, of each class of remedies generally, the lecturer describes 



192 



Bibliographical Notices. 



[Jan. 



the effects prodaced by them, the circumstances modifying these effects, the 
conditions of the system favourable and unfavourable to their employment, the 
different modes of introducing them into the system, the rules to be observed 
in their administration, and, lastly, their uses and application in various dis- 
eases. The consideration of these several subjects being preceded, in the case 
of emetics, cathartics, and diuretics, with a brief description of the organs by 
which their primary and chief operation is experienced. 

We acknowledge the general accuracy of the author's teachings on all the 
subjects embraced in the lectures before us. Upon some particular points, it 
is true, we cannot entirely coincide in the correctness of the views advanced by 
him. It is probable, however, that, had it been consistent with the plan of the 
lecturer to have considered, more in detail, the therapeutic application of the 
remedial agents treated of, even the few particulars in which we differ from 
him would not have existed 

In preparing the manuscript of Dr. Beck for the press, the editor assures us 
that his agency " has been merely ministerial where it seemed to him " that 
the language could be made more clear, verbal alterations have been made;" 
and " where, as happened in a very few instances, a fact was stated inaccu- 
rately, the statement was corrected by him." In a few places, he has added 
a few words, where he thought, by so doing, he could " make the book useful 
to students; in all cases these additions, ^neillo imputantur,'' are included in 
brackets." 

Many of what are termed the "new remedies," are unnoticed in the lectures 
of Dr. Beck; the editor felt no disposition to supply the omission. Two sub- 
jects, however, he believed it proper to introduce. 

" One was, to be sure," Dr. Oilman remarks, " a new and fashionable, and 
a most extravagantly vaunted agent, cod-liver oil. Still, it appeared to me that, 
in a matter with which the mind of the profession is at present so much occu- 
pied, something ought to be said. I have, therefore, prepared an article which, 
I hope, may not be useless. The other subject, to which I referred, is Anoes- 
thetics. These agents have been introduced during the period of Dr. Beck's 
failing health, and he never lectured on them. He knew that they were noticed 
incidentally by two of his colleagues, Dr. Parker and myself, and that I devoted 
considerable time to a rather full consideration of the whole subject; hence he 
felt the less necessity for treating of them. When, however, his lectures came 
to be presented to the profession in a book ; and, especially when they were 
offered to students as a text-book of materia medica and therapeutics, it was 
obviously proper that a consideration of these agents, whose use is so wide 
spread, and whose utility is scarce now a subject of doubt, should appear in it. 
I accordingly prepared an article on anaesthetics, in which, while I have tried 
to do justice to a class of remedies, the introduction of which into practice is, 
I firmly believe, a great boon to humanity, and when used in the particular de- 
partment of the healing art to which I have for years devoted most of my time 
and thought, enables us to rob labour of half its sorrows, and almost all its 
terrors, I have, at the same time, and even with more earnest efforts, laboured 
to impress on the minds of those as yet unfamiliar with their use, the lessons of 
caution and watchfulness without which, I know, these agents are and must be 
ministers of death. On the question of how far I have succeeded in this task, 
I feel very great solicitude; I am, I hope, ever mindful of the responsibility 
which attaches to one who earnestly commends to the notice and the favour of 
the profession a practice which has, we know, destroyed more than a score of 
lives, and which many believe has been fatal to a much larger number. I 
know that, in urging upon the profession the duty, for such, in certain cases, I 
deem it, of using anaesthetics, I may be instrumental in the destruction of 
human life ; and I desire, by the most earnest warnings, by cautions in season 
and out of season, to clear myself of any responsibility for fatal events, which 
may and must result from the careless use of those drugs. Used with constant 
care, watched with unceasing vigilance, they are safe, and most beneficial 
agents; used rashly and thoughtlessly, they are so dangerous, so almost cer- 
tainly fatal to life, that such use of them involves, in my judgment, an amount 
of moral guilt little short of that which attaches to manslaughter. To impress 



1852.] 



Beck's Materia Medica and Therapeutics. 



193 



these opinions, and the consequent cautions, on the readers of the article on 
anaesthetics, was the motive constantly present to my mind in its preparation. 
If I have succeeded; if those who read it j2;ain from it lessons of care, caution, 
and watchfulness, I shall be satisfied ; if not. Letter, far better, that it had not 
been written." 

This is an honest, and, we believe, correct statement in reference to the dan- 
gers attendant upon a careless and improper resort to anaesthetics, and it is 
these dangers which should cause every one, before resorting to them, in any 
case, to pause and weigh well all the advantages to be gained from their em- 
ployment, and satisfy himself that these advantages are of an importance that 
will outweigh all possible risk incurred by their use. Is the use of anaBsthetics 
necessary under any circumstances ? Will their administration, in any instance, 
increase the safety of the patient's life? If it be admitted that the only benefit 
to be obtained from their employment is the abolition of pain, then arises the 
important question, are we so well acquainted with their effects as to be able 
so to manage them, in every case, that, while we destroy by them suscepti- 
bility to pain, we can be certain that, in placing the patient under their use, he 
shall incur no risk of death or permanent injury of any kind? It may be our 
duty to inflict pain to save life, but can scarcel}^ be warranted in risking life 
merely to avoid pain. 

We now quote, for the benefit of our readers, Dr. Oilman's rules for the ad- 
ministration, of anaesthetics; they will, we fear, scarce find them sufficiently 
explicit to lead to the safe employment of agents, admitted to be, when "used 
rashly and thoughtlessly'^ — " so dangerous, so almost certainly fatal to life," 
that such a use of them is declared to involve " an amount of moral guilt little 
short of that which attaches to manslaughter." 

" Circumstances modifying the effects of Anaesthetics. — On this subject we want 
facts. Age does not seem to contra-indicate their use, as Professor Gross says 
he has administered chloroform to patients of every age, from sixteen months 
to seventy years, without any evil effects. Sex, too, seems to have little influ- 
ence, and if such power belong to climate, we are yet unable to appreciate it." 

" States of system unfavourable and favourable to the use of Ancesthetics. — The 
conditions under which ansesthetics are most likely to act irregularly are, 1. 
Very great plethora. From the observations of Dubois and others, it would seem 
most prudent to remove this plethora before the agent is administered. Yet, 
having done this, care must be taken as to the manner in which the anaesthetic 
is given, as it usually acts much more promptly immediately after a bleeding, 
or when the system is much reduced, than under other circumstances. In the 
case to which I have already alluded, where its effects were so rapid and so 
serious, the chloroform was given immediately after a free bleeding. 2. The 
presence of serious disease of the heart or great vessels has been, by Mr. Wakley 
and others, said to contra-indicate the use of anassthetics. This has been denied ; 
certainly the existence of such organic affection should make us pause and duly 
reflect on the question ; and, if we judge it best to use the anaesthetic, no doubt 
great care should be taken to shorten, or avoid altogether the period of excite- 
ment." 

" Rules for the administration of Ancesthetics. — 1. The patient should not take 
food immediately before the operation. 2. The mind should be as far as possi- 
ble calm and composed. 3. Quiet around is of the utmost importance; loud 
talking, addressing questions to the patient, &c., are all likely to interfere with 
the production of the anaesthetic state. 4. As to how rapidly the patient should 
be hurried through the state of excitement, there is difference of opinion, and 
a different rule should prevail, as the agent is ether or chloroform. If ether is 
used, the stimulation is often troublesome, and the deeper stages of narcotism 
not readily produced. We ought, therefore, to hurry forward the process ; place 
the cupped sponge over the nose and mouth, not pressing on the skin, but quite 
near, and urge the patient to take full free inspirations — let them follow each 
other as rapidly as is consistent with their being fdl and deep. As to chloro- 
form. Professor Simpson advises that the patient should be plunged as rapidly 
as possible into complete anaesthesia. This is not the course I would recom- 
mend. I think the practitioner will do better to feel his way a little, and allow 



194 



Bibliographical Notices. 



[Jan. 



the effects of the agent to develop themselves gradually. There will every now 
and then be trouble with the stimulating effects, but there will be less danger. 
5. Care should be taken that the supply of atmospheric air is at all times ade- 
quate. There is little doubt but that several of the fatal cases depended on an 
inadequate supply of air. 6. Watch the case from the first inhalation till con- 
sciousness and sensibility have completely returned. One person should in all 
operations have charge of the anaesthetic, and he should think of nothing else. 
In one fatal case, the attendant who should have watched the patient, was look- 
ing at the operation, and the man died. The person who has this charge should 
keep his finger on the pulse every single moment of the time ; not one beat should 
the heart give that his finger does not take note of. The moment the pulse 
begins to flag or flutter, the inhalation should cease, and a puff or two of fresh 
air be bloAvn into his face. As to the degree to which the effects should be 
carried, it will differ in different cases. In natural labour, we need ordinarily 
go no further than to obtund pain, and this can generally, I think, be done 
without disturbing consciousness. In surgical operations, complete relaxation 
of the muscles and profound sleep are generally required. This state, however, 
must be watched, and when the breathing becomes stertorous the inhalation 
should be suspended. If the breathing is irregular or interrupted, the danger 
is most imminent, and every means of keeping up respiration should be resorted 
to. Artificial respiration is the sheet-anchor in such cases, and I have known 
great danger removed by prompt and continued artificial respiration. Every- 
thing will depend on the coolness and self-possession of the operator. 7. When the 
patient is allowed to emerge into consciousness, everything that can startle and 
shock should be avoided, and the brain allowed quietly to recover its equipoise. 
Ammonia, oxygen, galvanism, &c., &c., have been proposed as remedies in 
excessive anaesthesia. They amount to nothing. Artificial respiration is the 
alpha and omega." 

Such then are the best rules that can be given to guide us in the use of a 
dangerous agent. Vague and indefinite, however, as they unquestionably are, 
nevertheless, in our present ignorance of all the circumstances which may, in 
any given case, modify the effect of the ansesthetic administered, so as to render 
that effect a boon to the patient in the prevention of pain, or to convert it into 
a poison fatal to life, they are the only ones experience has as yet taught us. 

D. F. C. 



Art. XX. — Southern Medical Reports; consisting of General and Special 
Reports on the Medical Topography, Meteorology, and Prevalent Diseases in 
the following States: Louisiana, Alabama, Mississippi, North Carolina, South 
Carolina, Georgia, Florida, Arkansas, Tennessee, Texas, California. To be 
published annually. Edited by E. D. Fenner, M. D., of New Orleans ; Mem- 
ber of the American Medical Association, etc., etc. Volume II., 1850, 8vo. 
pp. 494: New Orleans and New York, 1851. 

We fear that the real value of these reports is not fully appreciated by the 
medical profession. Assuming the general accuracy of the facts and observations 
comprised in them, of which the character of their respective authors must be 
considered a sufficient guarantee, they present a mass of valuable information on 
points of the greatest interest, connected with the topography, etiology, patho- 
logy, and therapeutics of a most important class of diseases ; information which 
can be derived from no other source of equal authority. The personal obser- 
vations of a physician accustomed to the clinical study of any form of disease, 
and to the investigation of the character of the particular localities and circum- 
stances under which it most commonly and to the greatest extent prevails, cannot 
fail to instruct. And when we have a series of these observations, from a number 
of practitioners, similarly circumstanced, we are furnished with materials from 
which we may form a judgment in reference to its causes, character, and treat- 
ment, of immense importance, whether as a basis to direct us in the measures to 



1852.] 



Fenner's Southern Medical Reports. 



195 



be adopted for its prevention, the mitigation of its severity, and its cure, or to 
direct us, in our personal study of the form of disease in question, to those points 
upon which doubt or obscurity still exists. 

The present volume of reports is equal in interest to the first, and in some 
Jespects, perhaps, superior. It includes contributions in reference to the diseases 
of eight different States, including California, vs^hich, although north of the 
boundary originally prescribed, it, nevertheless, as the editor correctly remarks, 
must be isothermalhf^ considered strictly a Southern State, as will appear 
by the communications from Dr. Thomas M. Logan, of Sacramento city. 

The leading topics of the first volume, namely, endemic fevers, epidemic 
cholera, and colic, medical topography and meteorology, are presented under 
somewhat different views in this, whilst several new subjects, such as the 
peculiarities of the negro race, the diseases of California, sanitary measures, 
and vital statistics, are introduced and discussed with marked ability. 

All the reports of the present series are replete with matter of a deeply inte- 
resting and instructive character, but none more so than those on the State of 
Louisiana. 

We quote the following paragraphs from the report of Dr. E. H. Barton, on the 
meteorology, vital statistics, and hygiene of the latter State. In our researches 
into the nature of malaria as a cause of endemic and epidemic disease, atten- 
tion is unquestionably to be paid to the changes which have occurred, preceding 
or concurrent with the appearance of these diseases, in the physical condition of 
the atmosphere, which changes, there is every reason to believe, exert as decided 
a morbific influence as does the vitiation of the air by foreign impurities, the 
result of the decomposition of large masses of either animal or vegetable matter, 
while they invariably augment the baneful influence of the latter. It is even 
more than probable that to the changes in the physical condition of the atmo- 
sphere alone are to be attributed the production of wide-spread epidemics ; 
the vitiation of the air by foreign impurities can only occur within very circum- 
scribed limits, and when the free circulation of the atmosphere within those 
limits is prevented by local causes. 

" That the qualities of the medium in which we live," remarks Dr. Barton, 
"should produce disease, when there are great vicissitudes; when we are sub- 
jected to them under conditions we are not accustomed to; or when the system 
shall have acquired increased susceptibilities from other influences, is not at all 
extraordinary. In fact, it seems to be in precise accordance with the common 
sentiments of mankind. ?»Iedical men, before the laws of meteorology were 
understood, refining upon this universal assent, deeming it to be vulgar, or not 
sufiiciently recondite for the mysteries of scientific faith, thought proper to 
ascribe to another agency the production of the great mass of human maladies. 
Of the many wonderful powers of this supposititious agent (miasm), with attri- 
butes certainly incompatible with any known agent, I have nothing to do now ; 
I only call attention to some of the sensihle properties of the atmosphere, to 
show that these qualities, so common as to be passed by almost unnoticed, are of 
the greatest importance in the preservation of our health, and that, together 
with personal indulgences and some hygienic conditions, to be hereafter adverted 
to, most of the conditions productive of a pathological state are fulfilled. 

" Probably no general fact is more universally observed than the connection 
of great devastating epidemics with remarkable distemperatures of the air ; 
unusupJ droughts or deluges, great extremes of heat or cold, continued calms, 
or winds blowing for a long time from unusual quarters, hurricanes, etc.; nay, 
whatever has been unusual in the elemental conditions, so has varied the health 
of man — indeed, of inferior creation too, for they have their epidemics as well 
as man. Astrology ascribed them to the condition and attraction of the heavenly 
bodies, and various have been the conjectures and superstitions of man in rela- 
tion to it. The ' constitution of the atmosphere,^ for good or for ill, with 
whatever term it has been clothed, has exacted the general credence of mankind. 

" It is a curious fact, in corroboration of this statement, that these .meteoro- 
logical zones or conditions occur in cycles of tolerable regularity, in periods of 
about seventeen years. So has been the occurrence of great epidemic visitations. 
The recent cholera and other disastrous diseases are well-known exemplifications 
No. XLV.— Jan., 1852. 14 



196 



Bibliographical Notices. 



[Jan. 



of it. Such lustra, and of about the same duration, have been palpably recog- 
nized in agricultural pursuits — in the return of good or bad crops — of the sugar 
cane dying and being reproduced every seventeen years ; and in the animal 
creation, in the visitation of locusts, the flight of pigeons, etc. By and by the 
returns will be more exact, the coincidence more clearly shown, the law estab- 
lished, or it will be abandoned. The spirit of philosophic research is now 
abroad, and the lovers of truth will assuredly find it. 

" Since the birth of meteorology, and it has been a very slow and tardy partu- 
rition ; as it unfolded its treasures, as successive data have been recorded, 
comparisons been instituted, diseases have been ascribed to one or other of 
the changes that have been noted. Certain maladies are known to predominate 
during certain seasons, and these are characterized by variations of heat and 
cold ; and so of the different climates, north and south. The most remarkable 
characteristic, and what has earliest struck the attention of mankind, has been 
the duration of certain temperatures. It was, however, soon seen that varia- 
tions of temperature alone were not sufficient to account for all the different 
diseases prevailing in certain seasons and climates, for when these were the 
same, the influence on the health of man was very different. More or less rain 
was found to have its influence ; so was the condition of the winds, and so of 
atmospheric pressure. These still not satisfying inquiry into the causes of the 
influences we experienced, the hygrometric condition was investigated, and it 
was soon seen that the greatest value was to be attached to it ; that it was the 
only varying constituent of the atmosphere, for in that light it should be looked 
upon, though not technically so ; that it was often independent of rain and 
temperature, which fact, extraordinary as it appears to the scientific reader, my 
journal clearly demonstrates ; and that it readily accounted for most of the 
influences ascribed to miasm. In proportion, then, to the observation of atmo- 
spheric phenomena, so has been their connection with morbid conditions. 

*' The hygrometric condition is less known and appreciated than any other, 
and probably more nearly influences our sanitary state and enjoyments. Its 
frequent and great changes are often mistaken for thermometric alterations ; 
many persons, feeling the change they experience, are astonished, on looking, 
to find the stationary condition of this latter; and these changes are sometimes 
very great. So far as philosophical experiments have gone, hardly a doubt 
exists of the fact that the winds that have obtained their appelh\tions — such as 
the simoom, kamsin, etc. — from the pestilences they have borne upon their 
wings, have derived their qualities mainly from their hygronietrical states; one 
is loaded with vapour, saturates the atmosphere, prevents the decarbonizing 
power of oxygen on the bh)od, relaxes the system, increases the freedom of the 
secretions by which the blood is impoverished and kept yirepared for the im- 
portant purposes of life (?) ; while another, on the contrary, desiccates the blood, 
dries up the secretions by which it is depurated, and arrests vital action, by ra- 
pidly depriving the system of the fluids requisite to sustain the organs in the due 
performance of their functions. In either excess, then, life is jeoparded, and 
much more than by mere extremes of temperature. This is clearly proved by 
the fact of the sickliest countries and seasons having the highest dew-point; 
that in elevated, or other regions, or at sea, where the highest salubrity is en- 
joyed, a medium hygrometric state is usually present, except when influenced 
by a prevalence of particular winds, that convey certain amounts of moisture 
with them. I think the present state of meteorological investigations will au- 
thorize me to announce these as established facts." 

We have not quoted the above paragraphs because they contain anything 
calculated to throw much light upon the etiology of endemic or epidemic dis- 
eases, but from the importance of the views advocated in them, and the necessity 
of keeping these constantly'- in mind, in our investigations of the causes of dis- 
ease. The influence of atmospheric distemperies in disturbing the healthful 
performance of the vital functions of the animal system has been again and again 
insisted upon, and enforced by a long series of observations ; the general fact 
may, indeed, be considered as established. The nature of the physical changes 
in the air by which disease is most liable to be produced is, however, as yet 
unsettled. We may feel satisfied that the cause of disease in the so-called 



1852.] 



Smith's Ojyerative Surgery. 



197 



malarial districts is to be attributed to the excessive moisture of the atmosphere 
which there prevails, often in conjunction with a defective ventilation ; but we 
want the positive evidence that such is the fact. We feel gratified, therefore, 
that the physicians of the South have commenced to direct their attention to this 
subject; and from the accurate scries of meteorological observations collected 
by them, the careful analysis of these, and the comparison of the reigning forms 
of disease with the condition of the air in reference to its several physical pro- 
perties, preceding and accompanying their prevalence, we anticipate more posi- 
tive results than have heretofore been arrived at. 

The several notices contained in the present volume of the dengue or break- 
bone fever, as it occurred in various sections of the Southern States, are replete 
with interest, and furnish important materials towards a correct history of its 
symptomatology, its ordinary duration and course, however much they may be 
deficient in facts calculated to enlighten us in regard to its true pathology and 
etiology. This strange affection M^ould appear to be rather painful and trouble- 
some than unmanageable or fatal. 

We find, in one or more of the communications embraced in the volume, 
allusions to, if not a positive recognition of, the identity of the yellow fever of 
the South with the more aggravated forms of bilious remittent fever. We have 
long suspected this identity ; we could in no other way reconcile the discre- 
pancy between the accounts given by those who have described the form of dis- 
ease denominated yellow fever by the Southern physicians, and the genuine dis- 
ease as described by the older American practitioners, and by those who have 
studied it as it prevails along the shores of the Mediterranean, and in the West 
Indies. 

The editor apologizes in a note at the close of the volume for the non-appear- 
ance of a considerable amount of matter he has in hand, ready for publication, 
but omitted from the want of room. We would respectfully suggest whether, in 
future, for we have no idea that the work will be permitted to close with the second 
volume, it would not be better to omit such portions of the proceedings of 
societies as have not a direct bearing upon the medical topography, meteorology, 
and endemic and epidemic diseases of the Southern States, and devote the 
space taken up by these with matter of more general interest, and more ger- 
main to the leading object of the present work. 

We earnestly recommend these southern reports to the patronage of the 
medical profession. Although they would appear to be mainly interesting to the 
physicians of those States to which they have immediate reference, still, they 
contain much matter from which, in consequence of its applicability to the 
illustration of important points in the etiology, pathology, and therapeutics of 
disease generally, the physicians of the Northern States also may derive profit- 
able instruction. D. F. C. 



Art. XXI. — A System of Operative Surgery, based upon the Practice of Svrgeons 
in the United States, and comprising a Bibliographical Index and Historical Re- 
cord of many of their Operations during a period of Tico Hundred Years. By 
Henry H. Smith, M. D., Surgeon to the St. Joseph's Hospital, &c. &c. Illus- 
trated by numerous steel plates. Phila.: Lippincott, Grambo & Co., 1852. 

We are informed that, **in consequence of the delay necessarily connected 
tvith the engraving of the illustrations, the publishers have deemed it desirable 
to issue this work in parts. Each part will be complete in itself, and they 
will succeed each other as rapidly as is consistent with the proper execution of 
the plates." The portion of the work already published, and which is now be- 
fore us, comprises Parts I. and II. 

Want of space and of time, consequent upon the recentness of its appearance, 
precludes anything like an extended notice of this volume in the present num- 
ber of this Journal. And, moreover, injustice to Dr. Smith and to ourselves, 
we prefer not to enter into a critical examination of his labours until they shall 



198 



BibUographical Notices. 



[Jan. 



have been completed, and we shall have the opportunity of investigating the 
finished work. We shall novr, therefore, merely give a synopsis of the plan 
which the author has pursued, and of the contents of this fragment of his book. 

Dr. Smith is already pretty generally known to the profession as the author 
of a very good treatise on minor surgery, and as the translator of a work of M. 
Civiale, '* On the Medical and Prophylactic Treatment of Stone and Gravel." 
Many of those, moreover, who have, during the last few years, pursued their 
medical studies in this city, have had the pleasure of listening to his instruc- 
tions as Assistant Lecturer on Demonstrative Surgery in the University of Penn- 
sylvania, and as Lecturer on the Principles and Practice of Surgery in the 
Philadelphia Medical Institute. 

In view of the many volumes which have been published, during the last ten 
years, upon Operative Surgery, the issue of another might seem to be uncalled 
ibr, and therefore unwise. But Dr. Smith has endeavoured to give to the work 
upon which he is engaged a peculiar character, by taking as its basis the his- 
tory and present condition of this department of medicine in this country. 
How well he shall have succeeded in his undertaking, and the amount of the 
benefit which he may thereby confer upon the profession, we do not now propose 
to inquire. His task is certainly not a very easy one. It will require patient and 
toilsome research into periodical and standard medical literature, and the exer- 
cise of much discrimination in the winnowing and sifting of the mass of pub- 
lications. We sincerely hope that the result of his labours will prove satisfac- 
tory to himself and his readers. Our impression of it, so far as we have 
examined it, is certainly very favourable. 

This volume ofi'ers to us in the first place a sketch, very concise, of the his- 
tory of surgery, which is followed by an "Historical Record of American 
Surgery.^' The last-named section is interesting, as it tells us how the medical 
profession has progressed in our land. And it may be a source of honest pride with 
us to find that, from the dawning of our nation to its present noonday effulgence, 
the names of physicians are amongst the brightest and worthiest on the pages 
of our history, both as civilians and soldiers. Dr. Samuel Fuller was one of 
the pilgrims in the "May-Flower;^' Dr. John Winthrop was one of the earliest 
governors of the Connecticut Colony ; in 1746, Dr. Colden was the Lieutenant- 
Governor of New York; in 1775, Dr. Joseph Warren, acting as General of the 
infant army of the Revolution, fell at the glorious engagement of " Bunker Hill;" 
in the same year. Dr. Benjamin Rush was a member of the American Congress, 
and signed the Declaration of Independence ; in the same year, too, Dr. Mercer, 
better known as General Mercer, fell at the battle of Princeton. And from the 
number of worthy men who are now in the ranks of our profession, we have 
no doubt that, should the country need their service in the field, or in the 
council, many will be found who will prove themselves not inferior to those 
early champions of Liberty and Right. But a glance at this historical sketch 
which Dr. Smith has presented shows that the first physicians of this country 
did good service to the cause of their science. In 1721, Dr. Cotton Mather 
introduced the practice of inoculation in Boston, — the same year in which 
Lady Mary Wortley Montague was inoculated in England. Dr. Bayley, a sur- 
geon of New York, described the false membrane formed in croup, and recom- 
mended the treatment of this disease by bleeding, tartar emetic, and calomel — 
a practice which twenty years subsequently, was advocated by Dr. Cheyne, of 
Dublin, and has been claimed as having originated with him. Many important 
surgical operations, too, were first performed in this country, and numerous 
additions have been made to the Materia Medica. 

In looking over the bibliographical index which Dr. Smith has prepared, and 
which occupies many pages, it will be seen that much has been done by Ame- 
rican surgeons towards the literature of the practical part of their science. 

In many respects, the profession has been unfavourably circumstanced as 
respects the cultivation of the science of medicine in this country ; and to those 
who are acquainted with the nature of the disadvantages under which medical 
men have here laboured, it can scarcely be a matter of surprise that no more 
has been accomplished by them. But these impediments are gradually dis- 
appearing, and our honour and reputation are certainly involved for the future 



1852.] 



Constructidh of Hospitals for Insane. 



199 



for the cultivation of original scientific investigations. In other sciences, and 
in the useful arts, our progress is very satisfactory ; in medicine, we cannot and 
should not conceal or deny that vre are behind our European brethren. 

Dr. Smith has divided this portion of his work into two parts : The first 
embraces the general duties and elementary operations of a surgeon. He in- 
culcates the importance of a certain preparation of the patient for operations, 
the necessity of exercising care in the planning of all operative procedures, and 
in the preliminary arrangements, and the duties of the surgeon and assistants 
during, and subsequent to, the operation. A section is devoted to the instru- 
ments required for the elementary operations, and to the selection, preservation, 
and modes of employing them. Another section treats of the important subjects 
of the arrest of hemorrhage, and the treatment of wounds made in operations. 

The second part describes the operations practised upon the head and face. 
Before giving an account of these, the author details the anatomical peculiarities 
of each region. His authorities are chiefly Blandin and Professor Horner. 
The operative procedures which are described are selected from American and 
foreign sources, and the author's own opinion concerning their comparative 
merits is also announced. A very important feature in this connection is the 
introduction of a concise statement oi tha pathology of the afiections for which 
operations are performed, inasmuch as a thorough acquaintance with this de- 
partment of surgery can alone constitute the true basis of treatment. 

The author's descriptions of the different operations are generally clear and 
satisfactory, His style of writing, however, is often open to criticism, and we 
would call his attention to this point, because, although he himself doubtless 
knows precisely what he wishes his readers to understand by his remarks, he 
nevertheless exposes himself in many instances to the charge of being obscure, 
or something even worse than this. We will cite a few illustrations. On page 
22, he says: " In some few instances the production of pain, and the develop- 
ment of the patient's sensibility, are the object of the operation, as is seen in 
the use of stimulants for the cure of hydrocele." He does not mean, certainly, 
that the object of the surgeon in this case is to produce pain, but to excite a 
certain modification of vitality in the serous membrane of the scrotum, of which 
pain is one of the usual indications. Again, on page 29, in discoursing upon 
the duties of the surgeon after an operation, with reference to the proper 
regimen to be pursued, he observes : An operator will not err in this part of 
his duty if he bears in mind the great principles of all sound practice, viz.. 
Inflammation." The true interpretation of this sentence is not quite so palpable 
as that of the other. In his preliminary history of Surgery, he informs us that 
"the earliest individual directly spoken of in connection with the practice of 
surgery, and the reputed originator of the science, is the mythological person of 
Chiron, the centaur, supposed to have been born in Thessaly at some unknown 
period." Such blemishes as these the author can easily avoid, and we allude 
to them, in a perfectly friendly manner, in order that he may in future pay a 
little more attention to his mode of expressing his excellent precepts. 

The publishers have fulfilled their part in this undertaking in a very satis- 
factory manner. The paper and the type of the book are much superior to 
most of our medical publications. The drawings, which are very numerous 
and well chosen, are chiefly copied from the beautifully-executed plates of 
Messrs. Bernard and Huette ; many are faithfully drawn from nature. They 
fire a great ornament to the book, and cannot fail to be serviceable to the ope- 
rator. F. W. S. 



Art. XXIL — Report on the Construction of Hospitals for the Insane, made hythe 
Standing Committee of the Association of Medical Superintendents of American 
Institutions for the Insane, at its Meeting in Philadelphia, May 21st, 1851. 

The Association of Medical Superintendents of American Institutions for the 
Insane was organized in 1844, and holds its annual meetings in difierent sec- 



200 



Blhliographical N&tices. 



[Jan. 



tions of the United States. On its list of members are found the names of 
most of those who of late years have devoted themselves to the care of the in- 
sane, or are now engaged in the Superintendence of Public Institutions for 
their treatment. 

The want of some definite principles to guide those, to whom has been en- 
trusted the erection of new Hospitals, has been so universally felt, that we 
believe we shall be doing a favour to the public by promulgating the results of 
the experience of practical men on the subject, especially so, at the present 
time, when so many States of the Union are engaged in providing new insti- 
tutions, or in enlarging those already in existence. In the report referred to 
above, will be found a series of propositions on the subject, which, after mature 
deliberation, received the unanimous approval of the Association, and were 
directed to be published as the well-settled opinions of its members. These 
propositions, twenty-six in number, are as follows, viz : — 

1. Every Hospital for the Insane should be in the country, not within less 
than two miles of a large town, and easily accessible at all seasons. 

2. No Hospital for the Insane, however limited its capacity, should have 
less than fifty acres of land, devoted to gardens and pleasure-grounds for its 
patients. At least one hundred acres should be possessed by every State 
Hospital, or other Institution for two hundred patients, to which number these 
propositions apply, unless otherwise mentioned. 

3. Means should be provided to raise ten thousand gallons of water, daily, 
to reservoirs that will supply the highest parts of the building. 

4. No Hospital for the Insane should be built, without the plan having been 
first submitted to some Physician or Physicians, who have had charge of 
similar establishments, or are practically acquainted with all the details of 
their arrangements, and received his or their full approbation. 

5. The highest number that can with propriety be treated in one building is 
two hundred and fifty, while two hundred is a preferable maximum. 

6. All such buildings should be constructed of stone or brick, have slate or 
metallic roofs, and as far as possible be made secure from accidents by fire. 

7. Every Hospital, having provision for two hundred or more patients, should 
have in it at least eight distinct wards for each sex, — making sixteen classes 
in the entire establishment. 

8. Each ward should have in it a parlour, a corridor, single lodging-rooms 
for patients, an associated dormitory communicating with a chamber for two 
attendants ; a clothes room, a bath room, a water closet, a dining room, a dumb 
waiter, and a speaking tube leading to the kitchen or other central part of the 
building. 

9. No apartments should ever be provided for the confinement of patients, 
or as their lodging-rooms, that are not entirely above ground. 

10. No class of rooms should ever be constructed, without some kind of 
window in each, communicating directly with the external atmosphere. 

11. No chamber for the use of a single patient should ever be less than eight 
by ten feet, nor should the ceiling of any story occupied by patients be less 
than twelve feet in height. 

12. The floors of patients' apartments should always be of wood. 

13. The stairways should always be of iron, stone, or other indestructible 
material, ample in size and number, and easy of ascent, to afibrd convenient 
egress in case of accident from fire. 

14 A large Hospital should consist of a main central building with wings. 

15. The main central building should contain the offices, receiving rooms 
for company, and apartments, entirely private, for the Superintending Physi- 
cian and his family, in case that ofiicer resides in the Hospital building. 

16. The wings should be so arranged, that if rooms ai-e placed on both sides 
of a corridor, the corridors should be furnished at both ends with movable 
glazed sashes for the free admission of both light and air. 

17. The lighting should be by gas, on account of its convenience, cleanli- 
ness, safety, and economy. 

18. The apartments for washing, clothing, &c., should be detached from the 
Hospital building. 



1852.] 



Construction of Hospitals for Insane. 



201 



19. The drainaf!;e should be under ground, and all the inlets to the sewers 
should be properly secured to prevent offensive emanations. 

20. All Hospitals should be v^armed by passing an abundance of pure fresh 
air from the external atmosphere, over pipes or plates, containing steam under 
low pressure, or hot water, the temperature of which at the boiler does not ex- 
ceed 212 degrees F. and placed in the basement or cellar of the building to be 
heated. 

21. A complete system of forced ventilation, in connection with the heating, is 
indispensable to give purity to the air of a Hospital for the Insane, and no ex- 
pense that is required to effect this object thoroughly, can be deemed either 
misplaced or injudicious. 

22. The boilers for generating steam for warming the building should be in 
a detached structure, connected, with which may be the engine for pumping 
water, driving the washing apparatus, and other machinery. 

23. All water closets should as far as possible be made of indestructible 
materials — be simple in their arrangement, and have a strong downward ven- 
tilation connected with them. 

24. The floors of bath rooms, water closets, and basement stories, should as 
far as possible be made of materials that will not absorb moisture. 

25. The wards for the most excited class should be constructed with rooms 
on but one side of a corridor, not less than ten feet wide, the external windows 
of which should be large, and have pleasant views from them. 

26. Wherever practicable, the pleasure-grounds of a Hospital for the Insane 
should be surrounded by a substantial wall, so placed as not to be unpleasantly 
visible from the building. 

The importance of these propositions to the comfort and welfare of the insane, 
and to an economical administration of such establishments, can be fully appre- 
ciated only by those who have been actually engaged in the direction of Hos- 
pitals, and are thoroughly familiar with the many and glaring defects of con- 
struction to be found in most of the existing institutions. 

It will readily be perceived, that various other points, in regard to which 
there is nearly unanimity of sentiment, might have been introduced, but it 
was deemed desirable that nothing should be promulgated on this subject 
that did not meet with entire approval from the whole Association. The 
twenty-six propositions which we have copied from the published proceedings 
are all of this character; there is no one of them that is not important; and 
they go sufficiently into details to justify us in saying that they will form a safe 
guide for any body of men entrusted by the community with the important 
duty of providing new institutions for the insane. If faithfully carried out in 
any Hospital, we hazard little in saying that it will be found quite equal in 
every respect, if not much more convenient and comfortable, and better adapted 
for all the purposes required in such an institution, than any one now in ex- 
istence, while its cost will not be greater than is generally required for the 
very imperfect plans too often adopted. 

The medical profession, in every State, ought at least to possess sufficient 
influence to prevent Boards of Building Commissioners from perpetuating bad 
plans, or assenting to the crude designs, of perhaps eminent architects, who, 
whatever may be their abilities, really know little of the requirements of a 
Hospital for the Insane, when it is so easy to ascertain the essential features 
about which there is shown to be no difference of opinion among them who 
have a practical acquaintance with the subject. We know not how medical 
men can do a greater favour to the afflicted, or to the community, for their 
interests are identical, than by insisting hereafter, whenever a new Hospital 
is to be built, that it shall at least come up to the requirements of these twenty- 
six propositions ; and that anything less shall be regarded as proof that those in 
authority have been derelict in duty, and have been unfaithful in the per- 
formance of an important public trust. 

T. S. K. 



202 



BihliograjpMcal Notices. 



[Jan. 



Art. XXIII. — The Journal of PsijcJiological Medicine and Mental Patliology. 
Edited by Forbes WiNSLOW, M. D., London (published quarterly). Nos. 1 — ^16. 
January, 1848, to October, 1851. 

The obvious want of facilities for studying mental diseases, which is every- 
where noticed, ought naturally to give the profession a particular interest in 
the class of periodicals specially devoted to their investigation. So long as this 
very important and not uncommon class of maladies is scarcely noticed in the 
course of instruction given, even in the best medical schools, and while the 
large charities for the pauper insane are closed against every attempt to give cli- 
nical instruction within their wards, the J ournals which are devoted to this branch 
of medical science, and are strictly professional in their character, seem to be 
alDiost the only medium by which medical men can keep accurately informed 
of the progress made in this department of the profession, or be made familiar 
with the zeal with which industrious and accurate observers are prosecuting 
the study of every point of interest connected with it. 

There are now three Journals devoted to insanity and kindred subjects, which 
are familiar to all who are engaged in the care of the insane, but are much less 
known to the profession generally than is commonly supposed. 

The American Journal of Insanity, with which our readers are most familiar, 
was commenced by the late lamented Dr. Brigham, at Utica, N. Y., and con- 
ducted by him up to the period of his death. It is now under the editorial 
management of Dr. T. Romeyn Beck, and has been the medium of communication 
for a large amount of valuable information and important essays on most sub- 
jects connected with the welfare of the insane. It has completed its seventh 
volume. The Annales Medico-Psycliologiques, edited by Baillarger, Brierre de 
Boismont, and Cerise, is published quarterly in Paris, and from its commence- 
ment it has been ably conducted. The Journal of Psychological Medicine and 
Mental Pathology, to which we propose calling the attention of our readers more 
particularly, originated with Dr. Forbes Winslow in 1848, and continues to be 
edited by him with decided ability. In the estimation of all right thinking 
men, it should have an increased value from the fact that it is particularly ad- 
dressed to the members of the medical profession ; and that all that class of 
articles intended for the public as a means of notoriety are carefully excluded 
from its pages. 

The plan of Dr. Winslow's Journal embraces original communications, ana- 
lytical and critical reviews, giving well-digested abstracts of all works on 
psychological subjects, translations from continental journals, a full discussion 
of the subject of medical jurisprudence, carefully prepared notices of the opera- 
tions of the different hospitals for the insane, and a great variety of other useful 
and interesting selections. 

As a medium for communicating the results of the experience of those de- 
voted to this branch of the profession, the Psychological Journal has been 
highly valuable, and its pages have furnished a large amount of practical infor- 
mation not to be found elsewhere. 

Besides the usual variety, the numbers already published contain several 
elaborate articles devoted to an analysis of the reports of American institutions 
for the insane, with details of their arrangements and modes of management. 
The marked impartiality and liberality of feeling with which these institutions 
have been noticed in this Journal, have brought them very prominently before 
the European public, and have illustrated most strikingly the great progress 
which has recently been made in this country in the management of the insane, 
and the improved character of the hospitals prepared for their treatment. 

Want of space prevents our doing more on the present occasion than simply 
referring very briefly to the contents of the last number of this excellent period- 
ical, but which will be sufficient to show the importance and value of the sub- 
jects under discussion to the whole body of the profession. 

The first article of forty-one pages, on sleep, dreaming, and insanity, is an 
elaborate notice of the writings of Drs. Symonds, Fosgate, Wood, and Bennett, 



1852.] RegUtry of Births, Marriages, and Deaths in Massachusetts. 203 



on these and kindred subjects, and is distinguished by deep research and a 
philosophical view of the whole subject. The second article is a review and 
criticism of the recent work of Mr. Bailey on the theory of reasoning. Next 
follows a notice of the Lunatic Asylums of Ireland, including special reference 
to that very important subject, the establishment of a central asylum for the 
reception and custody of insane persons, charged with the commission of crimi- 
nal offences. To this succeeds a review of the reports of the principal British 
asylums, embracing a large amount of valuable information, apparently drawn 
up with great care, and an earnest desire to give reliable statistical tables. 
Article 5th is devoted to the subject of medical evidence in cases of insanity ; 
and the 6th, styled the murderer's confession, presents one of the most extra- 
ordinary instances on record of a propensity to take life, or at least a reckless- 
ness in the commission of murder, difficult to be accounted for; the case in 
point is cited by the reporter of it to establish the importance of preventing, 
by every possible means within the reach of the law, the guilty from escaping 
punishment. 

Among the original communications which follow, is one on improving the 
condition of the insane by the establishment of additional asylums for the mid- 
dle classes, by Henry Muiiro, M. D., and a translation of a paper b}'' M. Brierre 
de Boismont on the last sentiments of suicides. The proceedings of the last 
meeting of the association of medical officers of British hospitals for the insane 
are given in full, followed by articles on criminal and on chancery lunatics, and 
various short notices. 

We regard the establishment and successful prosecution of this periodical as 
having done much to promote the best interests of the insane, and the able 
manner in which it has been conducted from its commencement as highly 
honorable to its distinguished editor. We cordially recommend it to the patron- 
age and support, not only of all specially interested in the custody and treat- 
ment of the insane, but to the members of the profession generally, as giving 
reliable information in regard to mental science, and as inculcating sound doc- 
trines on all matters connected with the treatment of insanity. T. S. K. 



Art. XXIV. — Eighth Beport to the Legislature of Massachusetts, relating to the 
Registry and Returns of Births, Marriages, and Deaths, in the Commonicealth of 
Massachusetts, from May 1st, 1848, to January the 1st, 1850. 8vo. pp. 130. 

This interesting and important document, though furnished officially by the 
Secretary of State, the Honorable Amasa Walker, is understood to have been 
drawn up for him by Dr. Josiah Curtis, of Boston, who had bestowed consider- 
able labour in its preparation. We have heretofore noticed the annual reports 
of the same kind, and are gratified to find in the present, evidences of great im- 
provement, not only in the increased amount of original matter presented, but in 
various other respects. We shall proceed to lay before our readers some of the 
interesting observations presented in the analysis which follows the tabular 
statements. 

The report under notice at present includes the 20 months between May 1st, 
1848, and December 31st, 1849, embracing an analysis of 38,313 births, 10,951 
marriages, and 30,595 deaths. During the time specified, the State has been 
visited by the Asiatic cholera, and also by other severe epidemics, the fatal 
ravages of which contributed to swell the bills of mortality beyond those of 
any other period since the establishment of the system of State Registration. 
Former reports show that the average annual number of deaths registered in the 
State during the previous five years was 9,438, while during the eight months of 
1848 embraced in the present report the number was 9,735, and for the twelve 
months of 1849, the aggregate mortality reported was swelled to 20,860! In 
this comparison with former years, it is necessary to bear in mind the some- 
what curious fact, that the city of Boston was, in 1849, for the first time included 
among the places which made returns to the Begistration Office, similar to those 



204 



Bibliographical Notices. 



[Jan. 



presented by other cities and districts in the State. It is also proper to observe 
that the increased improvement manifested in making out reports would tend 
to swell the returns, even where no unusual epidemics or other causes co- 
operated to produce such increase. This last-mentioned result is encouraging 
to those in other States, where exertions are making to establish systems of 
registration. Perfection must not be expected in the outset, and the first aim 
should be to make a beginning. The experience of a few years in Massachu- 
setts has shown a gradual advance towards perfection, which gives the best 
hopes for the future, there as elsewhere. 

Among other matters embraced in the report under notice, the sudden and 
very great increase of the foreign population throughout the State, but more 
especially in the metropolis, is not the least interesting. The city of Boston 
contains the larger proportion of foreigners, amounting to no less than 46.37 
per cent., or nearly one-half the total population. The foreign population in- 
creased 70.2 per cent, from 1845 to 1850, whilst the native American portion 
actually suffered a decrease of 2.27 per cent. 

Of 63,466 foreigners ascertained to be living in Boston in 1850, 52,923 hailed 
from Ireland, 2,666 from Germany, and 7,877 were from various other coun- 
tries. "In ward number eight," says the report, " we find the largest num- 
ber of Irish (7,964), the smallest number of Germans (36), and the smallest 
number of the coloured population (only two). This section of the city con- 
tains the least number of inhabited houses, and at the same time the greatest 
number of persons to a house, there being an average of 21.18 individuals to 
each house ! Two houses in the ward contain 19 families each ; 5 houses 
were occupied by 10 families each : 14 houses by 9 families each ; 32 by 8 
families, and 56 by 7 families each !" In the whole city, there are, between 
the ages of 5 and 15, 12,143 children of natives, and 12,132 children of foreign 
parentage. In 1830, the proportion of the foreign population throughout the 
State was estimated at only 1.58 per cent. ; in 1840, at 4.72 per cent. ; whilst 
in 1850, it is calculated to constitute 20.20 per cent. In the city of Boston, as 
has been already stated, the proportion of foreigners is nearly one-half, being 
66,072, whilst the native Americans amount to 73,418. Of the total population, 
namely, 136,884, there were 66,072 males, and 72,716 females. 

Among the new items of information contained in this report, we find the 
sexes of the deceased designated, whilst for every city and district embraced 
in the returns for 1849, the average age at death has been carefully computed 
from the records. 

Under the head of Deaths from Zymotic Diseases, we find the following 
remarks, relative to epidemic cholera, which exhibited its usual preference for 
particular classes of citizens, or such as were subjected to particular habits of 
life. 

Of the total number reported as having died, in Massachusetts, of cholera, 
in 1849, namely, 1,188, the proportion from cities was 944. 

Of the 707 cases reported as having occurred in Boston, 572 were among 
foreigners, 460 of which were Irish, whilst the proportion of native Americans 
was but 135. 

Diarrhoea, so usually associated with epidemic cholera, was quite fatal in 
1849, the deaths reported under the head throughout the State amounting to 
209, of which 109 were in the cities. 

Dysentery prevailed as an epidemic preceding the cholera, and produced a 
heavy ratio of mortality during the last three years. "In its late visitations,'' 
says the reporter, "it differs as much, or more, from the ordinary type of that 
disease, as cholera differs from cholera morbus, or as typhus does from the 
plague of former times in older countries. The years 1848 and 1849 were 
particularly noted by the terrible mortality from this destroyer. For six years 
previous to 1847, the annual average of deaths from dysentery was only 236 ; 
but in 1847 it rose to 1,074, and during the succeeding 20 months which are 
embraced in this report, it numbered 4,590, of which 2,455 were in 1849. 
By far the most fatal year was 1848, immediately preceding the visit of the 
cholera. In the latter eight months of that year, 2,135, or nearly a fourth part 
(23.53 per cent.) of all deaths in the State, occurred from it, besides those in 



1852.] Rcgidrij of BiriJis, Marriages, and Deaths in Massachusetts. 205 



the city of Boston. In 1847 and 1848, this epidemic was principally confined 
to cities in the eastern part of the State ; but in 1849 it appears to have chosen 
more rural localities, G7.53 per cent, being in the country districts, and only 
32.47 per cent, in cities.^' 

It is noticed that small-pox seems to be on the increase, the amount of deaths 
reported from it in the year 1849 being 114, whilst, during the whole seven 
years previous to 1848, the total number of deaths was only 106. 

Of the 102,590 deaths with causes specified recorded in Massachusetts, in- 
cluding the city of Boston, within the last nine years (excepting deaths from 
violence), 22,342 are reported as from consumption of the lungs, making the 
]^roportion about 22 per cent., or a little over one in five of all the deaths from 
other causes. When to this amount, 4.88 per cent, of the deaths from all 
known diseases are set down as the proportion from inflammation of the lungs, 
the deaths from these two affections of the respiratory organs constitute 26.66 
per cent, of those from all sources. 

In the deaths by consumption of the lungs, a very great difference in the pro- 
portions of the sexes is observed. Thus, in the last five years and eight months, 
there were recorded 14,209 deaths from this disease, whose sexes were stated. 
Of these, 8,453 or 59.49 per cent, were females, and only 5,756 or only 40.51 
per cent, males. The excess of the former amounts therefore to 18.98 per cent. 

Diseases of the heart have apparently increased, causing 379 deaths in 1849. 
May not this perceptible increase arise from the fact that the diagnosis of 
diseases of the chest can be made out now with more accuracy than formerly, 
when a large proportion of the deaths from diseases of the heart were con- 
founded with pulmonary affections, and left without particular designation ? 

Of the deaths from childbirth, in 1849, much the largest proportion, 133, 
were in cities, whilst only 79 were from the rural parts of the State. Whether 
all the deaths from this source in the country are reported may be questionable ; 
but should this be the case, the causes of the disparity may afford an interest- 
ing subject of inquiry. 

The influence exerted by the seasons upon the bills of mortality are exhibited 
in a table, which shoAVS plainly that the summer months are by far the most 
fatal throughout the whole State. In the rural portions of the State, August 
and September present an aggregate of 30.70 per cent., which is more than 
double the amount of any other two contiguous months, and nearly double the 
amount of any two selected months. The two months just named show a 
difference from each other of only the half of one per cent, in the State ; but 
in the division of the city and country it is much greater, and stands against 
August in the former, and against September in the latter. In the city of 
Boston, the per centage amounts to 19.94 in August, and only 10.88 in Septem- 
ber. Previous to 1840, September was the most fatal month in Boston, whilst, 
prior to 1820, the most deaths occurred in October. This change has taken 
place gradually, as the city has become more densely populated, and more in- 
salubrious, particularly to the younger portion of the population. In the 
country districts, the abstracts show that September is at this period the most 
fatal of either of the twelve months. Of all who died in Boston during the 
months of August and September, 1849, omitting the deaths from cholera, 
which mostly prevailed among adults, 56.24 per cent, were under the 5th year 
of age. 

We find, in the last table in the series, that different proportions of deaths 
occur at different ages in cities and rural districts. Thus, whilst 49.81 per 
cent, of the city deaths were under the 10th year, only 41.11 per cent, of the 
deaths in the country were under the same age. Taking the whole mortality 
throughout the State, the proportion occurring under the 10th year was 45.11 
per cent. 

In the nine eastern counties, the ratio was 2.131 per cent., or 1 death in 46 
inhabitants ; while in the five western counties, it was only 1.87 per cent, or 1 
in 53.47. In Suttolk County (in which Boston is situated) the rate of mortality 
was the highest, being 3,645 per cent., or 1 in 27.44 of the living; and gene- 
rally it was in proportion to the density of the population, if we except some 
of the secondary cities, which had been taught by previous epidemics to uso 



206 



BihliograpTiical Notices. 



[Jan. 



preventive measures. When a division is made so as to include the principal 
cities, the annual ratio of mortality averaged 28.33 per cent., or one death to 
35.30 inhabitants ; vrhilst for the rest of the State, including the villages and 
rural districts, after making an allowance for towns making no returns, the 
rate of mortality was only l.TOi per cent., or one death per annum in 58.69 
inhabitants. 

Of the city deaths, nearly one-third (31.79 per cent.) w^ere under the 10th 
year of age. In the whole State more than a quarter (28.73 per cent.) of the 
mortality was under the 2d year of age, and one-half (49.81 per cent.) under 
the 10th year. 

Such facts prove clearly the existence of influences in some localities much 
more unfavourable to health and life than are to be found in others, and this 
is one of the greatest advantages to be derived from systems of registration, 
"without which extensive evils may exist almost unknown, and consequently 
remain uncorrected. The progress making in England in sanitary reform may 
be estimated from the following language used lately by one of its most strenu- 
ous advocates, the Earl of Carlisle, better known in this country as Lord Mor- 
peth. "The British Parliament has legislated on the conclusion, submitted 
with an accumulation of demonstrable evidence, that the causes of epidemic, 
endemic, and contagious diseases are removable, and that the neglect on the 
part of the constituted authorities to remove such causes, as far as they are 
obviously within their control, is a punishable offence. The foundation which 
the legislature has thus laid for the physical and consequently for the moral 
improvement of the people, is recognized. Half a century ago, it was said by 
a great physician and philanthropist (Rush), that the time would come when 
the legislature would punish communities for neglecting the known means of 
preserving the public health, and that prediction the British Parliament has 
been the first to realize." G. E. 



Art. XXV. — On Gout; its History, its Causes, and its Cure. By William 
Gairdner, M.D. Second edition, 8vo. pp. 300. London, 1851. 

In a notice of the first edition of Dr. Gairdner's treatise given in a former 
number of this Journal (October, 1849), a very favourable opinion was expressed 
of the pathological and therapeutical views advanced by the author. The judg- 
ment then given was the result of a very careful examination of the work, and its 
correctness is confirmed upon an equally close examination of those views as 
more folly set forth and exemplified in the new edition now before us. 

In the explanation of the causation and nature of Gout, presented by Dr. 
Gairdner, there is a clearness and precision which we look for in vain in nearly 
all the preceding writers on the disease ; while, at the same time, it is strictly 
consistent with what we know of the physiology and organic chemistry of the 
tissues and fluids which enter into the composition of the human organism, and 
furnishes a faithful exponent and guide in determining upon the proper prevent- 
ive and curative measures to be pursued. 

Besides a careful revision of the work throughout, and the enlargement and 
farther exemplification of all its practical parts, two entirely new chapters have 
been added to the present edition, replete with interesting suggestions in refer- 
ence to the functions of respiration and sanguification. The views of the author 
as to the formation of fibrin and gelatin, and the physiological office of the red 
globules, have so probable a foundation in truth as to demand a more full and 
close investigation. 

We had intended to present to our readers an analysis of the author's views 
on respiration and sanguification, but found, upon a second perusal of them, that 
to do him justice and to give a clear view of the facts and reasoning upon which 
his peculiar views are based would render it necessary for us to quote the greater 
portion of a chapter occupying forty pages. We must confine ourselves, there- 
fore, to the recapitulation with which the chapter closes. 



1852.] 



Gairdner on Gout. 



207 



" It has been proved, I think, beyond the possibility of cavil or doubt, that, 
in the act of respiration, and by a process of oxygenation, the amorphous albu- 
men is converted into the plastic fibrin, adapted to the uses of the system, and 
the formation of the softer muscular tissues. The fibrin is again, I imagine, 
by the removal of a portion of its carbon, by a further process of oxygenation, 
and by the addition of some atoms of nitrogen, raised to the condition of gelatin, 
■which is instantly carried to the organs for "whose nutrition it is destined. The 
fibrin supplies the softer and more perishable muscular substance. The highly 
organized gelatin nourishes the organs and containing vessels "where elasticity 
and ductility must be united to great resistance and strength. By a still greater 
development of the same process, the more elastic chondrin is educed to consti- 
tute the cartilages of the body. These functions of decarbonization and oxy- 
genation best account, in my mind, for the appearance of carbonic acid, and dis- 
appearance of oxygen in respiration, the points I proposed to illustrate at the 
beginning of this chapter. 

From this Diere enunciation of the vie"ws of Dr. Gairdner, on the physiologi- 
cal questions embraced in the foregoing extract, it "would be unfair to condemn 
those views as unfounded ^vithout a careful examination being made of the 
facts and arguments adduced by the author in support of them. 

As his explanation of the formation of gelatin will be considered, perhaps, 
the most heterodox, we shall lay before our readers the exposition he has given 
of his views in reference to this interesting subject. 

"Any difficulty,^' he remarks, "we have met with in accounting for the origin 
of fibrin is exceedingly enhanced when we seek to trace gelatin to its source. 
This substance is indeed the most perplexing of all animal products. It is not 
to be found in the blood ; and suddenly, Avithout any apparent stage of transi- 
tion, it makes its appearance in certain tissues, the skin, cellular membrane, 
tendons, cartilaginous structures, and bones. It is very extensively diffused 
through the body ; seems, indeed, to form a large part of its skeleton and frame- 
work, and yet is not found in its nutrient fluids." 

" The systematic chemists have solved this difficulty in a very easy and ex- 
peditious manner, by denying the existence of gelatin altogether as a part of 
the animal body, and assuring us that we form it in the act of ebullition. They 
do not, indeed, explain to us the process of extraction ; they do not tell us what 
molecular changes are accomplished, what elements are set loose or enter into 
new combinations, in order to furnish us with this educt of gelatin, which now, 
for the first time, exhibits itself. This axiomatic opinion was first, if I mistake 
not, emitted by Berzelius, and is now laid down in works on chemistry with a 
gravity and comfort that are very surprising. It would, indeed, be presumptuous 
in me to oppose myself, on a question purely chemical, to great authorities in 
this branch of science, had the decision been acquiesced in by physicians ; but 
they continue to think about and talk of gelatin as a substance having a real 
place in, and forming a distinct and essential part of animal bodies, hardly 
conscious, or not choosing to recollect, that chemists have decided anything in 
the matter.'"^ 

"It would indeed very materially abridge my labour, and aid me in my in- 
quiry, could I admit this position of the chemists. Were there no necessity of 
accounting for the presence of gelatin in the tissues, I should find no contradic- 
tion, seeming or real, of the doctrine I have adopted, that all the great organized 
principles which serve the purpose of building up the animal frame, take their 
origin in the blood, and that they are there from absolute necessity. The ques- 
tion now becomes an important one, and not less curious than important. Is 
gelatin an exception to all other organized substances ? Does it not arise in 
the process of sanguification? 

" Before giving an answer to this question, it is worth while to revie"w some 
of the properties, chemical and physical, of this substance, and its relation to 
other organic principles of animal bodies. The first circumstance which pre- 
sents itself worthy of observation, is the remarkable behaviour of gelatin under 
the influence of heat as contradistinguished from that of albumen. This latter 
substance undergoes a total change, when exposed to heat of a very moderate 
degree. "What the nature of that change is, is not yet known, except by its 
result, insolubility. But all the changes which gelatin undergoes are in strik- 



208 



BihliograpMcal Notices. 



[Jan. 



ing contrast. It only becomes soluble at an elevated temperature, and then, 
too, requires a laro;e proportion of fluid for its perfect solution, while soluble 
albumen seems diffusible through the smallest quantity of water. In contrast 
with albumen, too, which once coagulated cannot be led back to the fluid con- 
dition, some solutions of gelatin seem to have a difficulty in returning to a state 
of cohesion. If a portion of gelatinous tissue be treated with acetic acid, and 
a jelly obtained, it will readily liquefy on exposure to a very moderate degree 
of heat, but it does not return to its gelatinous condition on cooling ; yet it 
seems to exist united to the acetic acid, so far unaltered, that on the addition 
of an alkali, it reappears with properties unchanged. This phenomenon never 
exhibits itself in aqueous solutions of gelatin, and indeed the more durable 
quality of this substance may be looked upon as one of its marked character- 
istics, of which, probably, the retention of its properties in the experiment re- 
lated may be considered a striking illustration. 

" In remarkable coincidence with the more fixed quality of gelatin, is the 
fact that it enters into the construction of the most durable textures of the body, 
the cartilaginous, tendinous, and chondrinous structures, which are least liable 
to change or decay. In this, too, we can see the explanation of one of the great 
difficulties of the systematic chemists, that this substance cannot be obtained 
from the gelatinous tissues without decoction. Such firm textures cannot, in- 
deed, be broken down without a considerable disturbing force, and that this is 
the true reason, is proved by the fact, that gelatinous tissue, when in a state of 
subdivision, is by no means so rebellious to the action of hot water. 

"But gelatin in the tissues is undoubtedly in a state of very great condensa- 
tion. If twenty-five grains of the aponeurotic expansion of a sheep's foot be ex- 
posed to the action of acetic acid, it becomes transparent, swells to many him- 
dred times its original bulk, and yields a jelly which does not arrive at a fluid 
state till it has penetrated, or been penetrated by, an almost incredible amount 
of fluid. It is really difficult to say whether the gelatin absorbs the liquid or is 
absorbed by it, so strange is the manner of its solution. But this remarkable 
property of swelling and absorbing liquid, and the great amount of fluid re- 
quired to overcome its cohesion, and give it perfect mobility of parts, afford, in 
my mind, the explanation of many of its phenomena, and remove the veil of 
mystery which shrouds its condition in the living body. 

"Let me now call my reader's attention to the elemental constitution of gela- 
tin ; and with a view to its more perfect understanding, I will place it in con- 
junction with albumen, fibrin, and chondrin. I wish that the following analy- 
ses had been made, I will not say with greater care, for I doubt not they were 
made with that exactitude wliich characterizes the eminent individuals to whom 
we owe them ; but I wish they had been made with a knowledge, on the part 
of their authors, of the important deductions likely to be made from them. 
They are, however, at least, free from any suspicion of a bias to suit a precon- 
ceived purpose. 





Carbon. 


Hydrogen. 


Nitrogen. 


Oxygen. 


Sulphur. 


Phosphorus. 


Albumen, by Mulder 


54.086 


7.100 


15.650 


22.157 


0.677 


0.330 
















" " Scheerer 


55 097 


6.880 


15.681 




22.342 




Fibrine, " Mulder 


53.810 


6.910 


15.539 


23.052 


0.359 


0.330 












-A 




*' " Scheerer 


54.454 


7.069 


15.762 




22.715 




Gelatin, " Mulder 


50.050 


6.480 


18.350 


25.120 




















" " Scheerer 


50.557 


6.903 


18.790 


23.750 




Chondrin, " Mulder 


49 960 


6.630 


14.440 


28.590 


0.380 


No Ph. 


" " Scheerer 


49.496 


7.133 


14 908 


28.463 







"Whatever doubt may reasonably be entertained of the perfect accuracy of 
such minute operations, and their authors assume limits within which errors of 
oljservation are not only possible, but probable, still the same process of analysis 



1852.] 



Gairdner on Gout. 



209 



being followed, they are relatively correct, and form a very sure basis of gene- 
ral deduction. An inspection of the table seems to me replete with interest, 
and pregnant with useful suggestions. The coetaneous disappearance or diminu- 
tion of all the combustible matter, except hydrogen, with the increase of oxy- 
gen, is very striking. The proportion of carbon gradually diminishes as we 
rise through albumen and fibrin to the higher organization of gelatin and 
chondrin. Phosphorus altogether disappears in gelatin, and there are but 
traces of sulphur either in this substance or chondrin. Whilst these changes 
are going on, a great addition of azote takes place as fibrin passes into gela- 
tin, which is again dropped as the last substance is raised into chondrin. 

"To my mind all these changes are most striking. How is it, and for what 
reason is it, that amid a general consumption of these combustible elements 
hydrogen alone is spared and maintained in its primitive amount " I cannot 
help connecting the remarkable characteristics of the tissues we have been con- 
sidering, with the known qualities of the elements which enter into their com- 
position. All these ligamentous or gelatinous tissues have, and absolutely re- 
quire for the uses they serve, a great degree of elasticity, durability, and 
ductility. Their combustible and perishable elements are removed, while they 
receive a great addition of the least destructible of all the productions of- 
nature. The cartilaginous or choudrinous tissues, on the contrary, require no 
ductilit}- and tenacity, but even augmented elasticit}", the heavier ingredient 
nitrogen, is withdrawn, and the expansive hydrogen is maintained. These are 
not phantoms of the imagination. They appear to me indications of an import- 
ant truth, and to point in the direction of a sound philosophy,^' 

"I have not a doubt, that the atmospliere is the real source of the azote re- 
quired for the constitution of gelatin, and that this is another proof of the con- 
trolling force of those vital functions, which accomplish with ease changes im- 
possible by the unaided agency of any known scientific power. Edwards has 
proved the disappearance of nitrogen in respiration ; Magnus has clearly shown, 
its presence in the blood. Chemical analysis yields it in the organic princi- 
ples of this fluid; it seems to me that demonstration could hardly be closer or 
more complete. 

"We are now prepared to understand the origin of gelatin, without suppos- 
ing it to contradict the general law, that the great organized principles which 
serve for the construction and nourishment of the frame are eliminated in the 
blood. If gelatin be raised from the fibrin, as I think will appear at least 
probable, this change must take place in the course of the circulation. But, 
when the requisite addition of oxygen and nitrogen has been made to fibrin, 
the result will not be a jelly, which alone we are accustomed to consider gela- 
tin, but which is really a hydrate of gelatin ; the result will rather be, that 
radicle which we have seen swell into many times its original bulk, when ex- 
posed to the action of solvent fluids and heat. Not finding, however, within 
the current of the circulation, that great amount of moisture essential to its 
disintegration, it is necessarily and immediately dropped on the tissues where it 
is required." 

In the ensuing chapter, the author develops still further his views of the 
physiology of the blood, and bases upon them an explanation of the origin of 
constitutional disease. 

"We have already seen," he remarks, "what reason there is for believing 
that by the agency of oxygen the albumen is converted into fibrin. It is cer- 
tain, however, as I have already stated, that there is something here beyond a 
mere chemical operation. We cannot, by exposing albumen to the action of 
oxygen, obtain fibrin. I have kept them in contact and agitated them together 
for very many days, without any success. In considering this subject, our 
attention is mainly drawn to the most striking and most abundant organic 
principle of the blood, of which I have, as yet, made but little mention, the red 
globules. Everything in these remarkable bodies points out their great im- 
portance. Great, accordingly, has been the attention they have received ; and 
though much has been discovered, yet it has neither been commensurate with 
the labour bestowed, nor with the importance of the subject. We cannot yet 
certainly say that we know the use of the globules. We know even nearly as 
little of "^their chemical condition as of their physiological office." 



210 



Bibliographical Notices. 



[Jan. 



" They have been considered by nearly all physiologists, by Henle, Wagner, 
"Wharton Jones, &c., as floating cells, whose office is to elaborate the fibrin from 
the plasma of the blood. In opposition to this doctrine, Dr. Carpenter has 
proposed another explanation of the origin of the fibrin, founded certainly on 
strong and striking facts. He states that the animals whose blood does not con- 
tain any red particles, have, notwithstanding, fibrinous tissues, and that fibrin 
is found in the lacteal and lymphatic vessels, in which its presence cannot be 
accounted for by the agency of red globules, though white globules are there 
met with abundantly. Founded on these facts. Dr. Carpenter has advanced 
the opinion that the white globules are the source of the fibrin. 

The fact of fibrination in white-blooded animals does not present, to my 
mind, a great difficulty. Where there is a great difference of organization, 
there may be a difi'erence of office, without impugning that uniformity of the 
functions of nature which is so general a law. White-blooded animals may 
receive their white fibrous textures from white globules, while the red muscles 
of the vertebrata may proceed from red corpuscles. The presence of fibrin in the 
lymphatics, and thoracic duct, is a greater difficulty. But when I consider the 
condition of the fibrin in these vessels, its soft and undeveloped form ; and 
^ when I reflect on the very certain connection which seems now established be- 
tween the function of respiration and the origin of fibrin, I feel compelled to 
admit, that it finds its way into these absorbent vessels by direct absorption 
from the food, and not by excretion from the white globules. 

"But the determination of this question seems to me to be, at present, at 
least, more within the domain of pathology than of physiology. The great 
changes which take place in disease are accompanied by fluctuations in organ- 
ized principles which afford very striking indications of the bonds by which 
they are united to each other. Le Canu showed that a great increase of glob- 
ules took place in plethoric diseases. Andral and Gavarret proved that in 
inflammatory diseases, a great addition was made to the fibrin of the blood. 
Simon following, carried these discoveries out into much detail in a great 
variety of diseases ; but he took an additional step, by proving that the increase 
of fibrin was invariably attended by a diminution of the amount of the glob- 
ules, and that this process of fibrination was, in fact, carried on at the expense 
of these latter bodies.^' 

" Reverting to the pathology of the blood, let us see how far the facts brought 
to light by Le Canu, Andral, and Simon, coincide with and illustrate the views 
of the constitution of the blood exposed above. Did the stomach lose its office, 
and the appetite for food disappear, when the respiratory and assimilating 
functions are less active, weakness and faintness might result ; but the balance 
of the organized constituents of the blood would still be preserved. Our daily 
experience, however, proves to us, that not only may a good appetite be pre- 
served, but great gluttonous powers remain in spite of the almost total ruin of 
healthy assimilation. Though the nutrition of the body be thus, as it were, 
cut off in the middle, the stomach and bowels may still retain their office un- 
impaired, and the nourishing fluids be yet poured into the blood, there either 
to oppress the system, or run into the most painful forms of disease. 

" The observations of Le Canu have established the fact, that the point at 
which the assimilating function stops, when the system is oppressed, is the 
globulation of the blood. To use the language of the older physicians, remora 
takes place in the globules. Indeed, nothing can be more striking than the 
remarkable steadiness of the albumen both in health and disease. Le Canu 
found the proportion of albumen to vary extremely little in men and women, 
and in individuals of a sanguine and lymphatic constitution : but he found the 
mean ratio of the globules in women 99 ; while in men it rose to 132. In men 
of sanguine habit, he found the proportion of globules rise to 136 ; and in 
women to 126 ; while in men of lymphatic constitution the same proportion 
reached only 116.6, but in women it was as much as 117.3. {Etudes Chemiques, 
p. 83.) In scrutinizing the various analyses of the blood in disease, made by 
Le Canu, Denis, Andral, and Simon, the same great steadiness of the albumen 
is observed. In one disease only, albuminuria, does it undergo a great change, 
and then it sustains a diminution. The rule, too, is nearly invariably followed, that 



1852.] 



Giiirdner on Gout. 



211 



wherever a small addition is found to the nominal proportion of albumen, there 
is an adequate loss in the globules. Thus, in typhus, Le Canu found, in one 
case, globules 115, albumen 71; in another, globules 105, albumen 90 (p. 109). 
In five cases of heart affection, he found the mean of globules as low as 50, 
and the mean of the albumen as high as 80 (p. 110). In chlorosis, he found 
the proportion of globules as low as 55, and the albumen at 73 ; and in the 
same disease, two analyses made by Allie de Nancy, are quoted by Le Canu, in 
which the proportion of globules was found 91 and 85, while that of albumen 
was as high as 86 and 85. These results are fully confirmed by the researches 
of Andral and Gavarret. They found in a case of cachexia after ague, the 
globules 68.8, the albumen 72 (p. 75). In a case of diabetes mellitus, the 
globules 86, the albumen 80. In a case of dropsy from dilatation of the heart, 
the globules 68, albumen 85. In a case of cachexia following colica pictonum, 
globules 84, albumen 78. In nine cases of chlorosis, the average of globules 
59.6, of albumen 79.5. But Andral and Gavarret have proved the same tend- 
ency of the albumen to maintain its ordinary standard in diseases of a plethoric 
character. They have recorded one case of apoplexy in which the proportion 
of globules reached the very considerable amount of 175 ; and in which, not- 
withstanding, the albumen was still only 73 ; and in eight cases of the same 
disease, the average of the albumen was 74. 

" It may then, I think, be considered as proved, that though the albumen 
does undoubtedly alternate with the globules, tending to increase, when they 
fall off in amount, and to diminish when they abound, yet a much greater 
degree of stability characterizes it than the other organic constituents of the 
blood. These last oscillate in a very wide manner, increasing and diminishing; 
with the condition of the system and the health of the individual; when a 
stasis occurs in the blood, as in plethora, the arrest is in the globules. 

"In order to carry out the proof of this point, I desired some rabbits to be 
fattened for a great many days, and their blood to be examined. The following 
result affords a sufficient confirmation of the opinions of Le Canu and Andral: — 

Albumen. Globules. Fibrin. In 1000 parts. 

1 50.20 97.40 2.10 

2 49. 80.50 1.75 

3 48.20 75.43 1.96 

"The first of these rabbits was allowed its liberty in a room, and was some- 
what different in conformation from the others. 

"The last two resembled each other generally, in colour, form, bulk, and were 
closely confined in a box. The influence of this on their fibrin is manifest. 

"These organic changes are of much importance in the history of constitution- 
al disease. If the nutrient matters of the food be carried forward to this point, 
and here, instead of further elimination, be deflected to form lower products 
than the fibrin and gelatin, which would serve the healthy purposes of the body, 
we must look here both for our explanation of disease and our guide in the choice 
of a remedy.'' "Though I do not believe that scrofula takes its origin in a 
gouty state of habit, but that, like gout, it is to be referred to an original con- 
genital constitution, an idiosyncrasy of the individual; yet its outward mani- 
festations, its allied disease, tubercle, and many other tumours, may be traced 
to this source. All these growths abound in albuminous principles. Their 
progress is favoured by that which lowers the health and disturbs nutrition. 
The food which ought to proceed to the nourishment of the great organs and 
moving powers of the body, is interrupted in its course, and diverted to en- 
gender morbid processes or add to malorganizations already begun. In some 
individuals, extraordinary obesity is the result, and where subcutaneous fat only 
is created, it often serves as a relief to a plethoric habit. In others, low hydro- 
carbonaceous products show themselves in the urine in the form of sugar or 
urates. We can thus readily enough account for the striking phenomena of 
scrofula, phthisis, diabetes, gout, etc., according to the proclivity of the indi- 
vidual to one or other form of disease ; nor will it appear wonderful to the 
philosophic physician, that maladies of aspect so strikingly different, should 
yet own an origin in some respects common. 
No. XLY.— Jan , 1852. 15 



212 



Bibliographical Notices. 



[Jan. 



"These are not creations of the fancy. They are exemplified in the daily 
experience of every physician. What observation so common as the origin of 
scrofula in an impoverished condition of health? Is it not observed that a low 
quality of food tends to its increase, and a generous diet to its extinction? 
Does it not infest the close and pestilential manufactory ; all low, marshy and 
mephitic places ? Is it not cured by pure good air, as well as by good food? 
Do we not turn our scrofulous patients out of hospitals, for fear of the conse- 
quence to their health? In a pure and wholesome atmosphere the chest is 
thoroughly expanded, and the necessary changes in the blood well effected. 

" In gout the very same influences prevail. Only the tendencies of the con- 
stitution being different, the plethorous or superfluous albuminous matters show 
themselves in different local manifestations. The treatment, too, has various 
points of resemblance. Both are aided by whatever promotes the real nutrition 
of the body, and obviates stagnation and load in the vessels. 

"The opinions I have expressed above seemed to me to receive considerable 
confirmation from the fact discovered by Le Canu, that the placental blood con- 
tains a great increase of globules ; and that the blood of animals of powerful 
organization and active habits also abounds in them. Seeing these things, and 
seeing that arterial blood contains more globules than venous, the blood of men 
than that of women, boys, and old people ; the blood of persons of a sanguine 
than that of those of a phlegmatic temperament ; the blood of persons well fed 
than that of persons badly nourished ; the blood of the plethoric than that of the 
anaemic ; I could not doubt that the opinion of Wharton Jones and Carpenter 
(for in this at least they concur) is correct, and that within the globules the 
great development of organic principles and their adaptation to the uses of the 
body is affected. 

" But while revolving these things in my mind, it seemed to me certain, that 
the globulation of the blood was more a vital or organic than a chemical process, 
and that I should probably obtain an augmentation of globules by stimulating 
the nervous system, and an electro-magnetic influence occurred to me as the 
most likely means of accomplishing my object. A rabbit was, accordingly, thus 
treated ; but I was completely disappointed. No matter how moderate the in- 
fluence used, the breathing of the animal was excited in the highest degree, 
which prevented all arrest and accumulation of the globules. I obtained, how- 
ever, a very important confirmation of the former experiments on the effects of 
oxygenation. A stream of galvanic magnetism was carried from chest to spine 
for half an hour, at the end of which time the blood yielded 51.2 albumen, 
70.4 globules, 2.9 fibrin. 

" I have now gone through with the whole of this subject of the chemical and 
physical constitution of the blood, with a view to prove that rest and repletion 
lead necessarily to accumulation of globules ; that aeration is the source of the 
fibrin ; that by exercise the fibrin is carried forward to the tissues ; that by ex- 
ercise, air, and moderation in diet conjoined, constitutional disease, and particu- 
larly gout, may be avoided and cured ; that without them it is vain to hope for 
anything more than a respite from suffering for a greater or shorter period, 
or even only a suspension of the more acute symptoms of disease. These 
observations are so consonant with the observations of all men, learned and 
unlearned, of every age and every country, that they will, I feel persuaded, 
meet with ready belief.^' 

We must be very much mistaken in our opinion of the deeply interesting 
character of the views advanced by Dr. Gairdner in the foregoing extracts, if 
our readers make any objection to the length to which we have extended them. 

Admitting the accuracy of those views, and of this there would seem, to say the 
least, great probability, they afford an important clue to the pathology of con- 
stitutional disease, and to the rationale of the operation of the various hygienic 
means adapted to the prevention and cure of some of the most serious maladies 
to which the human frame is liable. 

The very full notice formerly given of the first edition of the treatise before 
us renders it unnecessary to enter into any further examination of the present 
one. From the extracts presented above our readers will be able to form a cor- 
rect opinion of the more important additions that have been made to it. 

D. F. C. 



1852.] 



Malgaigne's Operative Surgery. 



213 



Art. XXVI. — Operative Surgery, based on Normal and Pathological Anatomy. 
By J. F. Malgaigne, Professeur Agreg6 de la Faculte de Medecine de Paris, 
etc., etc., etc. Translated from the French by Frederick Brittan, A. B., 
M. J)., M. B. C. S. L. Illustrated by Wood Engravings from designs by Dr. 
Westmacott. Philada. : Blanchard & Lea, 1851, 8vo., pp. 565. 

Most of our readers, probably, are already familiar with this celebrated 
treatise of M. Malgaigne ; having been presented with it in the pages of the 
Medical News. To such as have referred to it, no commendation of ours is ne- 
cessary. To those who have not done so, it may be sufficient to state, that the 
original has passed through four or five editions in Paris ; that it has been trans- 
lated into no less than five Continental languages; and that "in the schools 
and hospitals of Paris, it is used as the standard work by students of all nations.'^ 
But in order that the scope and compass of the volume may be understood, we 
shall submit a sketch of its plan and arrangement. 

The book is divided into three parts, comprising severally, Elementary, 
General, and Special Operations. 

The first part treats in detail, as is the case with French authors generally, 
of the best methods of performing incisions, dissections, and punctures ; of 
cauterization — the materials, composition, and modes of applying cauterants, 
according to the ends to be attained in particular cases ; of the various means 
of arresting and preventing hemorrhage, both during and after operations, 
including the employment of the ligature, colnpression, astringents, styptics, 
cauterants, &c., &c. This section is peculiarly rich in its instructions, as the 
importance of the subject demands. The manner of effecting union of divided 
parts is also described in all its varieties ; and, finally, we have a chapter on 
the means of diminishing pain during operations. The measures described 
here, are the administration of narcotics ; " animal magnetism, which succeeded 
once on a woman whose breast was removed by M. J. Cloquet,'^ and which, 
we may add, has since proved efficacious in many other operations, but which 
has now very properly fallen into disuse ; distracting the patient's attention 
by conversation addressed to him ; celerity in operating ; cutting off" nervous 
communication between the part to be operated upon and the central nervous 
organs, either by pressure upon, or incision of, the nervous cords. At the time 
when Dr. Brittan's translation was made, (1846,) the employment of ether and 
chloroform had not been commenced; these ansesthetics have now superseded 
most others. 

The second part describes the common operations of minor surgery ; opera- 
tions performed upon the epidermis and its dependencies, including many ap- 
parently trivial, though reallyimportant, procedures ; operations on the teeth ; 
those especially affecting the skin and cellular tissue ; upon the muscles and 
their dependencies ; upon the nervous system and its dependencies ; on veins ; 
on arteries ^ on the bones and articulations : resections ; and amputations. On 
each of these subjects, all the popular and approved methods of operating are 
described and, in conclusion, that one is explained which M. Malgaigne's 
judgment and great experience lead him to consider the best, together with 
the reasons for such preference. 

Part third is devoted to the description of special operations, practised upon 
particular regions or organs. This comprises operations upon the eye ; the 
auditory apparatus ; the nasal region ; the mouth and its appurtenances ; the 
throat; the thorax ; the abdomen ; the rectum and the anus ; the genito-urinary 
organs of both sexes. 

The translator has added notes to the text with references, containing the 
details of some few operations omitted by the author, and of others which have 
been published since the date of the last French edition. The opinions and 
preferences of the most celebrated English surgeons, where they differ mate- 
rially from those of M. Malgaigne, have been also introduced, so that the pre- 
sent volume may fairly be considered "an encyclopaedia of the operative surgery 
of Europe.'' F. W. S. 



214 



Bibliographical Notices. 



[Jan. 



Art. XXVII. — The Principles and Practice of Obstetric Medicine and Surgery, in 
reference to the Process of Parturition. Illustrated by one hundred and forty- 
eight figures. — By Francis H. Ramsbotham, M. D., Fellow of the Royal Col- 
lege of Physicians, Consulting Physician in Obstetrics, and Lecturer on 
Obstetric and Forensic Medicine at the London Hospital, etc, etc. The sixth 
American, from the Enlarged and Revised London Edition. Ta ^iv aXKa fiav 
rtoXfjitoj xoLL /xetafio'KTi ifaxrji waXocrav rj Texvrj cyw^srat-. Philade^lphia, 1851: 
Blanchard & Lea. 8vo. pp. 540. 

The opinion advanced by us in reference to the value of Dr. Ramsbotham's 
treatise, as a systematic exposition of the principles and practice of obstetrics, 
in our notice of the first edition, has been fully confirmed by the very favourable 
reception the work has received both in Europe and the United States, and the 
demand which has been made for a new and revised edition, notwithstanding 
the numerous complete and valuable treatises on the same subject that have 
appeared within a few years past. 

The present beautiful edition of Dr. Ramsbotham's work is printed from the 
last London edition, carefully revised by the author, and enlarged by the addi- 
tion of a concise but very able sketch of the diseases of the pregnant and 
puerperal states, and of the interesting subject of abortion. Some valuable 
statistical tables, afi'orded by the practice of the Royal Maternity Charity, are 
appended to the volume. 

The whole of the illustrations, including the additional ones introduced into 
the last London edition, have been drawn anew, and will compare with, if they 
do not excel in beauty and accuracy, those to be met with in any work of a 
similar character with which we are acquainted. 

We recommend the present edition to the student and young practitioner of 
midwifery, as one of the best guides they can consult, to the principles and 
practice of the art. D. F. C. 



Art. XXVIII. — Medical Lexicon. A Dictionary of Medical Science; containing a 
concise Explanation of the various subjects and terms of Physiology, Pathology, 
Hygiene, Therapeutics, Pharmacology, Obstetrics, Medical Jurisprudence, <&c., 
with the French and other Synonymes ; Notices of Climate and of Celebrated 
Mineral Waters ; Formulcefor various Officinal, Empirical, and Dietetic Pre- 
parations, etc. — By RoBLEY Dunglison, M. D., etc. etc. Eighth edition, revised 
and greatly enlarged. Philadelphia, 1851 : Blanchard & Lea. Svo. pp. 
927. 

The medical student owes a debt of gratitude to Dr. Dunglison for the pre- 
paration of a medical lexicon so well adapted to assist him in the acquisition 
of the true import of the various technicalities made use of in the diiBFerent 
departments of medical science. Nor will the physician find the dictionary of 
Dr. Dunglison a useless incumbrance upon his reading table. In the perusal 
of medical authors, of even a comparatively recent date, technical words fre- 
quently occur, a definition of which would be extremely acceptable to many 
readers, and such definition they may obtain by a reference to the present work. 
There are very few terms that occur in even the most extended course of pro- 
fessional reading that have escaped the notice of the compiler, and the correct 
meaning of vrhich he has not given. The industry exhibited by Dr. Dunglison 
in the collection of the various technicalities that have been introduced into 
the several departments of medical science, as well by the older writers as by 
modern and contemporary authorities, is indeed surprising. Even when it 
might be supposed that he had exhausted the technical vocabulary, each suc- 
cessive edition of the Dictionary exhibits a very considerable addition to the 



1852.] 



Wood and Bache's Dupensatory. 



215 



terms contained in the preceding one, amounting in the edition before us, to 
four thousand terms not to be found in the last. 

It may be said that by the student and physician whose preliminary education 
has been such as should be demanded of the aspirant for, or the actual pos- 
sessor of the honours of a learned profession, no such aid as that afforded by 
the lexicon of Dr. Dunglison would be necessary. If nothing more were re- 
quired in reference to the several terms of art made use of by medical authors 
than simply their etymology, the remark would be perfectly true. As, however, 
the technical application of professional terms is in but a few instances indi- 
cated by their etymological meaning, the Greek and Latin, the French and 
Saxon learning of the reader will fail to reveal to him the true meaning of 
those terms. We recollect very well the disappointment we experienced when, 
in the early period of our medical pupilship, we consulted the otherwise ex- 
cellent lexicon of Baily, for the meaning of hcematocele, sarcocele, and hydrocele, 
WQ found no other definition than "hgematocele, from 'aaa, blood, and xrfKri, a 
swelling — a tumour formed by effused blood "sarcocele, from tfapl, flesh, and 
xTp^ri, a swelling — a fleshy tumour;" "hydrocele, from 'vScop, water, and xr^kri, a 
swelling— a tumour containing water." By comparing these with the definition 
of the same terms as given by Dr. Dunglison, the difi'erence between a mere ety- 
mological and a technical definition will be perceived, as well as the necessity 
of the latter to meet the object with which a medical lexicon is alone consulted. 

D. F. C. 



Art. XXIX. — Special Anatomy and Histology. By "Wm. E. Horner, M. D., 
Prof, of Anatomy, University of Pennsylvania, &c., &c. Eighth edition. 
Illustrated with anatomical figures. 2 vols. Philadelphia: Blanchard & 
Lea, 1851, pp. 510 and 500, 8vo. 

It is quite unnecessary to say anything in commendation of a w^ork which 
has gone through seven editions, and which has, therefore, received the stamp 
of the profession as to its value; and as we have, moreover, on former occasions 
noticed the successive editions of this Anatomy of Dr. Horner, it will be suffi- 
cient to state that in the present one he has introduced such improvements as 
the progress. of anatomy required, and added more than three hundred figures, 
many of them taken from nature, and intended to illustrate the author's pecu- 
liar views on points of anatomical structure. 

Useful as were the former editions, the present one w^ill be found more so, 
and to present greater claims to the favour which the profession has bestowed 
on its predecessors. 



Art. XXX. — The Elements of Materia Medica and Therapeutics. By Jonathan 
Pereira, M. D., F. R. S., and L. S. Third American Edition, enlarged and 
improved by the author, including notices of most of the medicinal substances 
in use in the civilized world, and forming an Encyclopaedia of Materia 
Medica. Edited by Joseph Carso.v, M. D., Professor of Materia Medica and 
Pharmacy in the University of Pennsylvania, &c. &c. Vol. I.: Blanchard 
& Lea, 1852. 8vo., pp. 838. 

The Dispensatory of the United States of America. — By George B. Wood, M. D., 
Professor of the Theory and Practice of Medicine in the University of Penn- 
sylvania, &c. &c., and Franklin Bache, M. D., Professor of Chemistry in 
Jefi'erson Medical College of Philadelphia. Ninth edition, carefully revised. 
Philadelphia: Lippincott, Grambo & Co., 1851. 8vo., pp. 1456. 

We have only room, at present, to call the attention of the profession to the 
editions just issued of these valuable and well-known works, which in our next 
number we propose to notice more particularly. 



216 



Bihliographical Notices. 



[Jan. 



The present edition of the first volume of Dr. Pereira's work bears the marks 
of careful revision. Several portions of it have been entirely rewritten, and 
every part carefully corrected. Numerous recent discoveries in natural history, 
chemistry, physiology, and practical medicine relating to materia medica have 
been introduced into it, and also all the improvements and emendations made 
in the recently-issued edition of the United States Pharmacopoeia, thus rendering 
it beyond question the most comprehensive and accurate treatise on the subject 
in the English language. 

We are told that the second volume is in press, and will be published in the 
course of the summer. 

In the ninth edition of the United States Dispensatory, the authors have 
made many additions and changes, rendered necessary by the recent publica- 
tion of new editions of the United States Pharmacopoeia and of the codes of 
London and Dublin, and have carefully revised the whole work, so as to main- 
tain the character of the work for fulness and accuracy. This volume is in- 
dispensable both to the American medical student and practitioner of medicine. 



Art. XXXI. — The Pliysician^s Visiting List, Diary, and Booh of Engagements 
for 1852. Philadelphia: Lindsay & Blakiston. 

We take pleasure in calling attention to this very useful and convenient little 
volume. It contains an almanac for the year ; a table of the proportionate 
doses of medicines for different ages ; a list of poisons, with their antidotes ; 
the code of ethics of the American Medical Association ; blank leaves, ruled 
and with the appropriate headings, for a visiting list for every day in the year, 
for memoranda, &c., for addresses of patients, for engagements, for wants, for 
list of things lent, &c. &c. With this in his pocket, the practitioner has 
always by him his list of patients, his professional engagements, and his day- 
book, as well as a diary for memoranda. It will, we are confident, be found 
80 convenient, that those once using it will not hereafter be willing to be with- 
out it. 



Art. XXXII. — A Treatise on the Dislocations and Fractures of the Joints. By 
Sir AsTLEY Cooper, Bart., F. R. S., &c. A new edition, much enlarged. Edited 
by Bransby B. Cooper, F. R. S., &c.. Surgeon to Guy's Hospital. With Ad- 
ditional Observations, and a Memoir of the Author. A new American Edi- 
tion. Philada. : Blanchard & Lea, 1851. 8vo., pp. 496. 

This eminently practical work is too well known for it to be necessary to do 
more than state, that the present edition embodies the results of the large ex- 
perience and observation of the author during his whole life, published with 
the advantage of the supervision of his distinguished nephew, and that it is 
also enriched with some highly valuable observations, by one of our own most 
experienced and illustrious surgeons, John C. Warren, M. D., of Boston. 

No medical library can be complete without a copy of this work. 



1852.] 



217 



aUARTEllLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES 

IN THE 

MEDICAL SCIENCES. . 



ANATOMY AND PHYSIOLOGY. 

1. Anatomical arrangement of {he Vaginal or deep JBursce 3fucosce. — In the 
No. for January last, of the London Journal of Medicine, Mr. Wm. Coulson pub- 
lished (see our No. for April last, p. 453,) a description of the subcutaneous 
bursse, and in a subsequent No. (Oct. 1851), he gives an account of the deep 
seated. By deep seated bursas mucosae, he means the synovial membranes 
usually vaginiform, interposed between tvro or more tendons, between tendon 
and bone, or between tendon and ligament, for the manifest purposes of pro- 
tecting the structures from the injurious effects of friction, and of facilitating 
motion. 

In the upper extremity, where we have chiefly to deal with morbid conditions 
of these bursse, the synovial membrane extends downwards as far as the distal 
insertion of the tendons, and upwards for some distance beyond the fibrous 
sheath. Each tendon is covered by a reflexion of this vascular membrane, and 
is loosely attached in the whole, or in part, of its course, to the walls of the 
canal, by a fold similar to the mesentery, and called meso-tendon. These folds 
limit the movements of the tendons in a slight degree ; they may be torn by 
some violent movement, and are occasionally the seat of disease. 

Anatomical Arrangement. Upon the dorsal surface of the wrist, there are 
distinct sheaths, — 1. For the extensor carpi ulnaris ; 2. For the extensor minimi 
digiti ; 3. For the extensor communis digitorum and the indicator ; 4. For the 
extensor secundi internodii pollicis ; 5. For the two radial extensors; and 6. 
For the extensores ossis metacarpi et primi internodii pollicis. Any one or 
more of these sheaths may become distended, and assume the characters of a 
bursal swelling. There are also five or six thecal sheaths on the palmar surface, 
and these are the most frequent seat of enlargement. Enlargement of the 
bursas in this situation is a most formidable disease. 

The sheaths of the extensor ossis metacarpi, and of the extensor primi inter- 
nodii pollicis, and of the extensor carpi radialis longior and brevier, merit 
special anatomical notice, as they are often affected with morbid changes. The 
two first, free in their fibrous sheaths, but covered by the same visceral layer of 
synovial membrane, can only be partially separated ; and there are some anato- 
mists who regard the two tendons as divisions of one and the same muscle. 
The two extensors of the radial side of the wrist are likewise retained in appo- 
sition by a common visceral layer of membrane, as far down as their point of 
separation to their respective insertions. The synovial membrane there leaves 
the extensor carpi radialis brevier, being continued only over the extensor lon- 
gior. Throughout their whole course a meso-tendon attaches them to the pos- 
terior wall of the sheath. 

Along the anterior or palmar surface of the wrist and forearm we have two 
sets of bursae ; some small, and often overlooked, others of considerable size. 
The palmaris longus and brevis are each enveloped in loose areolar tissue, 



218 



Progress of the Medical Sciences. 



[Jan. 



abounding in thick serous secretion ; and it is easy to comprehend how such a 
structure would become converted into a complete synovial sac under favourable 
circumstances. Some months ago, Mr. C. removed from the hand of a working- 
man a thick walled cyst, lying between the integument and the palmar fascia, 
and containing a sort of synovia. It had doubtless been originally a bursa, 
thickened by the constant pressure of the hand upon the hard iron handle of 
an immense hammer. The patient described it as originally a small elastic 
swelling, situated under a part of the hand where the skin had for a long time 
been very much thickened ; as the tumour increased in size, it pained the hand, 
and, interfering then with his work, made him anxious for its removal. 

The tendon of the flexor carpi ulnaris has a large and well-marked synovial 
sheath, especially loose and sac-like, near its insertion in the pisiform bone. 

Finally, there are the general synovial burs£e, which invest the tendons of 
the flexor muscles of the fingers, and of which many different anatomical de- 
scriptions have been given. Fourcroy and Bichat afl&rm that there is but one 
synovial bursa at the level of the carpus. Velpeau and Cruveilhier describe 
two — one common to the flexor tendons of the fingers ; the other proper to the 
long flexor of the thumb. Monro, Koch, and Bourgery, enumerate a much 
greater number of bursse in the anterior region of the wrist. 

Some of the deep bursae communicate directly with the joints. The bursas 
beneath the crureus muscle belongs to this order, likewise the large bursa below 
the iliacus and psoas ; its frequent communication with the hip-joint is well 
known. On the other hand, there are some which greatly resemble the cellular 
bursas in various stages of transformation towards the perfectly developed bursas. 
Of this kind is the extended bursal arrangement around the tendon of the plan- 
taris muscle ; another, equally remarkable, is between the middle tendon of the 
omohyoideus and the sterno-mastoid ; and a third interposes between the long 
abductor and extensors of the thumb on the one hand, and the radial extensors 
on the other. 

These structures resemble in many respects the serous membranes, and are 
yet more closely allied to the synovial, with which, as I have said, they are not 
uncommonly continuous. Upon their free surface we find a stratum of epithe- 
lium, supported by a basement membrane, and under this is a layer of blood- 
vessels, which may be filled with injection in a part rendered soft by partial 
decomposition. The blood-vessels form a net-work many layers thick. No one 
would suspect the existence of such a number of arterial and venous capillary 
tubes, from the examination of this structure in its normal condition after death. 
In many situations are found vascular fringes, first noticed by Havers in the 
joints, and described by him as the source of secretion of the synovia. They 
are found along the thecee of tendons, and in some of the bursas ih. the neigh- 
bourhood of the knee, and are composed of loops of vessels. Although we may 
not be able to prove experimentally what tissue secretes, and what absorbs the 
oily fluid contained in these sacs, yet we may infer that both processes go on 
most actively wherever the blood-vessels are most numerous. The vascular part 
of the bursa seems to cease where the membrane is firmly attached to a bone, 
as along the phalanges of the fingers. 

2. Supernumerary Fimbriated Openings in the Fallopian Tube. — M. A. Rich- 
ard, Jr., in making examinations of the Fallopian tubes, has discovered the 
occasional presence of supernumerary fimbriated extremities in these organs. 
He found them in five subjects out of thirty. The normal extremity existed in 
all the cases. Below this, at a distance of from some millimetres to two or 
three centimetres, there was a second orifice, furnished with fringes like those 
of the normal opening. A wire could always be passed through the fimbriated 
extremity, so that a communication between the interior of the tube and the 
peritoneal cavity could be made out. By gently pushing the wire towards the 
abdominal or the uterine orifice, it passed either through the true fimbriated 
opening, or into the uterus. 

Of the five subjects, one was a foetus at the full period, presenting two super- 
numerary orifices ; another was a girl, aged 15, who had not menstruated — she 



1852.] 



Anatomy and Physiology. 



219 



also had two additional orifices ; the other three were adult women, who each 
presented one supernumerary opening. 

M. Richard hints that this structure may throw some light on the cause of 
the abdominal variety of extra-uterine pregnancy. — Lond. Joy?', of Med., Oct. 
1851, from Reports of Biological Society of Paris in Gazette Med., June 28, 1851. 

3. On the Nerves of tlie Uterus. — While the discussion on the existence or non- 
existence of a special uterine nervous system is yet fresh to the memory, it may 
not be uninstructive to give an outline of the observations of an anatomist un- 
connected with either disputant. M. Boulard has recently read a memoir to 
the Societe de Biologic, in which he says: "The results of our dissections have 
constantly been opposed to those of Dr. Robert Lee, while they have been com- 
pletely in accordance with those of Mr. Snow Beck.^' The conclusions of the 
memoir are as follows : — 

1. The nerves of the uterus are derived from the hypogastric plexus of the 
lower sacral nerves and from the inferior mesenteric plexus, and are distributed 
in such an inextricable mesh that it is impossible to determine whether they 
originate in one system or the other. Nevertheless, we have constantly seen on 
the right side a nerve of considerable size coming out of the lumbo-aortic plexus 
and traversing the broad ligament to ramify on the uterus, ligaments, and fallo- 
pian tubes, sending also a few filaments to the ovaries. This nerve anasto- 
moses on the sides of the uterus with one or two branches from the hypogastric 
ganglia or plexus. 

2. The uterine nerves are few in number, and of extreme tenuity. 

3. These nerves do not increase in size during pregnancy. This the author 
has ascertained by dissecting, side by side, the uterus of a child of 12 years old 
and that of a women in the last stage of pregnancy. The only difi'erence appears 
to be in the width of the interspaces between the filaments ; there is no differ- 
ence in the size of the filaments themselves. 

4. The neck of the uterus appears to the author not to be entirely deprived 
of nerves ; he thinks that he has traced a filament into the os uteri. 

6. He has never discovered a uterine plexus ; but regards the appearance, 
so called, as deceptive, and to be produced by the peculiar interlacement of 
venules, lymphatic vessels, and muscular fibres. — Gaz. Med. de Paris, Aug. 16th. 

4. Influence of the Sympathetic Nerves and Spinal Cord upon the dilatation of 
the Pupil. — M. Julius Budge, professor of the University of Bonn, and M. 
AuGusTE Waller, communicated a statement of their researches upon the nerv- 
ous system. The first part, now submitted, relates to the action of the cervi- 
cal portion of the sympathetic nerve and of a part of the spinal cord on the dila- 
tation of the pupil. 

M. Waller had observed, a long time since, that when a nerve is divided, the 
distant portion becomes disorganized, so that the change may be detected by 
the microscope, while the central portion retains its normal state during a con- 
siderable period. Extending the same method of experiment and examina- 
tion to the sympathetic nerve, the author had found that the nervous centre of 
the cervical sympathetic cord was in some part below the second ganglion, that 
the direction of the cord is from below upwards. The division of the sympa- 
thetic cord in the rabbit (in which animal it is a simple cord), the lower por- 
tion was always found to have preserved its integrity, while the upper portion 
was disorganized. As the upper portion of the divided nerves preserve with 
their normal structure the same endowments as at the time of their division, 
the authors have galvanized the inferior part of the cervical sympathetic nerve 
without exciting any pain. The same experiment performed on the recently- 
divided nerve had shown that the strongest mechanical or galvanic irritation 
had failed to produce the slightest impression. The experiments of Miiller and 
other physiologists have proved that the ganglia do not arrest the sensitive im- 
pressions ; it remained only to recognize the purely motor or nutritive func- 
tion : this has been done by the following experiments : — 

Scarcely had a few revolutions of the machine been made, than already an 
enormous dilatation of the pupil on the same side took place, giving irrefraga- 



220 



Progress of the Medical Sciences. 



[Jan. 



ble evidence of the motor functions of the sympathetic cord of the sympa- 
thetic. This result, so remarkable, of galvanizing either the separated sym- 
pathetic trunk in the rabbit, or the re-united trunk of the pneumogastric 
and sympathetic in the dog, cat, &c., is as invariable as contractions of the 
limb from irritation of the sciatic nerve. At the same time that this experi- 
ment discovers the motor endowment of the sympathetic in the neck, it ex- 
plains, also, the cause of the contraction of the pupil, after the section of the 
nerve, shown first by Petit in 1712, and which has remained until now a barren 
fact in physiology ; for it is evident that, since irritation of this nerve produces 
contraction of the pupil, the contraction after section of the nerve can only be 
the result of paralysis of the dilator muscle of the pupil, in the same manner 
that paralysis of the extensors of the hand leave the hand closed by contraction 
of the flexors. 

For additional evidence it suffices to galvanize the third pair, in the rabbit 
during life, or immediately after death. By this means the contraction of the 
pupil is obtained. In thus galvanizing the sympathetic and the third pair, the 
alternate constriction and dilatation of the pupil may be obtained as surely as 
by the action of physical agents. 

In acting upon these two nerves, MM. Budge and Waller, have always had 
occasion to remark that the action of galvanism on the former always produces 
a gradual and continued expansion of the pupil, which occupies some moments 
in attaining its maximum, like most nerves placed under the influence of the 
sympathetic, while the return to the original state after the cessation of the 
dilatation is equally slow. The irritability of this nerve is preserved a long 
time after death. With the third pair, on the contrary, they have seen that 
the contraction is almost instantaneous, that the return to the former state is 
equally sudden, and that this nerve loses its irritability after it has been fre- 
quently excited, and that after death this property is rapidly lost. 

In order to reach the source of the motor power of the sympathetic, the 
authors had galvanized the nerve in the rabbit without dividing it, merely iso- 
lating it from its connections. On the first ganglion, and on the entire cord 
to the last cervical ganglion, dilatation of the pupil is produced. No result 
followed the galvanization of the ganglia or cord below this point. 

To ascend still higher, the spinal cord in a rabbit was denuded from the in- 
ferior portion of the dorsal region to the upper part of the neck. On galvaniz- 
ing the middle of the exposed portion, dilatation of the pupil was rapidly pro- 
duced. The part of the spinal cord possessing this property was that inclosed 
between the first cervical and the sixth dorsal vertebrae, and which they have 
designated the cilio-sphial centre. 

The maximum efi'ect is observed about the second and third dorsal vertebrae. 
When the two cervical sympathetics are intact, galvanization of the cilio-spinal 
centre influences both eyes ; but when one of these is divided, dilatation does 
not take place on that side from galvanization of the centre. When both sym- 
pathetics are divided in the neck, the pupils of both eyes remain undilated. 
When the spinal cord remains entire, galvanization of one side only produces 
dilatation equally in both eyes. If the spinal cord be divided longitudinally, 
and the two halves be separated by pieces of glass, irritation of one side afiects 
only the corresponding eye. If the cilio-spinal centre be removed in its totality, 
and the poles of the battery be applied to various parts of the dura mater of the 
spinal canal, the power of dilating the pupil is found to be situated only at the 
junction of the second and third dorsal vertebrse. 

Those causes which diminish muscular irritability after death, diminish the 
power of the cilio-spinal centre over the pupils. Cceteris paribus irritation of 
the spinal marrow produces effect only immediately after death. After death, 
the power over the eye is lost successively from the extremities to the centre 
of the cilio-spinal region. 

As a sequal to these researches, the authors propose to examine the influence 
of the intra-cranial portions of the sympathetic and of the fifth pair of nerves 
upon the movements of the iris. — London Medical Gazette, Oct. 1851. 

5. On the Reunion of Wounds of the Spinal Cord, with Restoration of its lost 
Functions. During the last three years, M. Brown-Sequard has made a con- 



1852.] 



Anatomy and Physiology. 



221 



siderable number of experiments, with the view of determining the degree of 
reparative power which exists in the Spinal Cord ; the results of which are 
very remarkable. The following is one of the most striking : The spinal 
cord of a pigeon was entirely divided between the 5th and 6th dorsal vertebrae ; 
and the operation was followed by complete paralysis of the posterior part of 
the body, as regarded sensibility and voluntary movement. At the end of 
three months, voluntary movements began to show themselves, in the midst of 
reflex actions ; and sensibility also reappeared. These powers gradually aug- 
mented ; and six months after the operation, the bird could stand for some min- 
utes, but fell if it attempted to walk. In the course of the seventh month it 
began to walk, but unsteadily, helping itself by its wings. By the end of the 
eighth month, it could walk slowly without support ; but if it attempted to walk 
fast, it fell over, unless it supported itself by its wings. Twelve months after 
the operation, it could run ; and when the account of the case was drawn up, 
fifteen months after the section had been made, its progression seemed in all 
respects normal, save that a certain degree of stiffness remained in its gait. 

In several Guinea-pigs, in which the section had only been made through 
one-half of the spinal cord, an incomplete return of voluntary power was ob- 
served within seven or eight months after the operation. In the case of one 
Guinea-pig, which had been subjected to this operation ayear before, and in which 
sensibility appeared to have been completely restored, and voluntary movement 
less completely, a careful examination was made of the injured part. It was 
found that the section had traversed both the posterior columns, as well as the 
anterior and lateral columns, and a portion of the gray substance on the right 
side ; all of which parts exhibited a sort of contraction, the continuity of the 
divided parts being re-established by a whitish cicatrix. On examining the 
substance of this cicatrix, it was found to be in a great part made up of fibres 
of areolar tissue, the direction of which was transverse or oblique ; but these were 
crossed by great numbers of nerve-fibres running in a longitudinal direction, 
which exhibited a double contour, and were uninterruptedly continuous through 
the whole extent of the cicatrix. Amongst these were scattered some gangli- 
onic corpuscles. A like reproduction of nerve fibres in the cicatrix of the 
spinal cord, has been substantiated by M. Brown-Sequard in two other cases. — 
Gazette MSdicale de Paris, No. 30. 

6. Further Experiments on Cadaveric Rigidity. — Following up the researches 
on which he has been some time engaged, M. Brown-Sequard has ascertained 
that if a current of arterial blood be re-established through muscles in which 
cadaveric rigidity has already begun to show itself, they cease to be rigid and re- 
cover their irritability. He found that when he connected the aorta and vena cava 
of the body of a rabbit, in which the cadaveric rigidity had already manifested it- 
self for between ten and twenty minutes, with the corresponding vessels of a living 
rabbit, so as to re-establish the circulation in the lower extremities, the rigidity 
disappeared in from six to ten minutes, and that in two or three minutes after- 
wards, muscular contractions took place when the nerve-trunks were irritated. 
These experiments have been repeated in various ways with the same result ; 
and theyfully justify the opinion of those who maintain that cadaveric rigidity 
is a vital phenomenon, and not an incidation of the death of the musples, which 
does not take place until the rigidity passes off. He has even succeeded in 
removing the cadaveric rigidity from the muscles of the decapitated body of a 
criminal, thirteen hours after execution, and two hours after the supervention 
of the rigidity, by the injection of defibrinated human blood. Thfe muscles 
lost their rigidit}^ and continued to contract on irritation, during the several 
hours.— te. Med. de Paris, Nos. 24, 27. 

7. Post-mortem duration of the ciliary movements in the Human Subject. 'Ry 
M. GossELiN. — The body of a decapitated criminal having been conveyed to the 
Ecole Pratique, the ciliary movement was recognized on the mucous membrane 
of the trachea, of the nasal fossae, and on that lining the maxillary, frontal, 
and sphenoidal sinuses, eight hours after death. The movements were still 
distinguishable, especially on the mucous membrane of the trachea, thirty-two 



222 



Progress of the 3fedical Sciences. 



[Jan. 



hours after death. The movement had ceased on the mucous membrane of the 
nasal fossas and of the sinues, fifty-six hours after death ; but this was perhaps 
due to the free exposure of these parts to the air ; for the vibration was still 
active on the mucous membrane of the trachea, where it was distinctly seen to 
the one hundred and sixty-eighth hour after death, after which putrefaction 
came on, and the movement ceased. In another case of the same nature, the 
ciliary movements were much less durable ; and this seemed to be consequent 
upon the earlier supervention of putrefaction, brought about by a higher tem- 
perature, the thermometer having ranged from 46° to 54° in the first case, and 
having risen to 68° in the second. — Gaz. MM. de Paris, No. 26. 

8. Physiological Experiments on the Bodies of Executed Criminals. — M. 
Duval, from his position as teacher of anatomy at Brest, enjoys frequent 
opportunities of examining the bodies of culprits executed by the guillotine. 
The theatre of anatomy is so near the platform that the bodies are received 
witliin five minutes of decapitation. Among the facts which he has ascertained 
are many which bear upon points in physiology, still sub judice. The follow- 
ing are the results of the first examination recorded in the Gazette MSdicale, 
Juillet 12th :— , 

A man was decapitated for murder, and the corpse was brought to the table 
in less than five minutes. The first thing which attracted notice was that the 
divided extremities of the carotid arteries were projected in successive jerks, 
at the same time ejecting small quantities of blood. The jugular veins bled 
continuously. 

No reflex action could be induced by any pinching, or other mechanical 
irritation. 

After devoting a quarter of an hour to the opening of the abdomen, the chest 
was laid open, and the heart was seen beating with great distinctness ; the 
left auricle, in particular, exhibited strong and perfectly regular action forty- 
four times in a minute, and continued to do so for an hour. 

Before the chest was opened galvanism was applied to the spinal marrow, 
and immediately caused movements of expiration and inspiration, accompanied 
by a hoarse noise in the larynx. After opening the chest galvanism was applied 
to the intercostal muscles, and caused the ribs to approach each other in a 
notable manner. The stomach was full of food ; but none escaped after its 
removal, in consequence of the rigid contraction of the cardiac and pyloric 
orifices. The bile was dark green, and of a gummy consistence. The spleen 
was empty and wrinkled, and could not be made to contract under galvanic 
action ; but the ureter contracted manifestly. The spermatic vesicles were 
filled with a liquid fluid, containing living spermatozoa. 

In another case, the pupils were contracted by galvanizing the third pair of 
nerves in the cranium. — Prov. Med. and Surg. Journ., Sept. 17, 1851. 

9. Uses of the Pancreatic Fluid. — Dr. Bernard believes that he has estab- 
lished the fact that the office of the pancreatic secretion is to saponify fatty 
matters. Dr. Bence Jones is not satisfied with this explanation, but considers, 
from other experiments performed by D. Lenz, that this fluid has no such 
power. His remarks are as follows : — 

" That the pancreatic fluid is not necessary to enable fatty substances to be 
absorbed, has been shown thus by Frerichs and Lenz. After they tied the 
pancreatic duct in cats, they were given no food for from twelve to twenty-four 
hours, so that all the pancreatic juice which was in the intestine might have passed 
out of it. Food, consisting of milk, fat, flesh, or butter, was then given ; and, 
after some hours, usually from four to eight, the animals were killed ; and 
they found, over and over again, that the lacteals and the thoracic duct were 
full of milky chyle. Frerichs put a ligature round the small intestines of ani- 
mals (who had eaten nothing for some time) much below the opening of the 
bile and pancreatic ducts; he then injected milk, or olive oil, or an emulsion 
of albumen and oil, into the intestine below the ligature, and, after two or three 
hours, he found the lacteals quite full of milky chyle. Experiments are de- 
tailed, in which butter was given in quantity to cats, but not one trace of the 



1852.] 



Materia Medica and Pharmacy. 



223 



volatile acids of butter could be found in the bowels, in the chyle, blood, or bile. 
Frerichs also found that other animal fluids, like the pancreatic juice, as soon 
as they began to undergo decomposition, effected as much change of fatty mat- 
ter into fatty acid and glycerine as the pancreatic fluid did. He also states, 
that the pancreatic juice, setting aside its chemical action, does not make a 
better emulsion — that it does not divide the fat or oil better than other animal 
fluids. He found, that when acidulated with hydrochloric acid, it had no action 
whatever on fat or on albumen ; that it had no power to act as a solvent of the 
albuminous part of our food. He states that, its uses are to change the starch 
into sugar, and to promote the secretion of the bile ; that, with the aid of the 
bile and the intestinal fluid, it effects, though it does not solely effect, a fine 
division of the neutral fat which is fluid at the temperature of the body ; but, 
further than this, he says there is no peculiar specific action of the pancreatic 
juice. The pancreas seems rather to be a supplementary gland to the salivary 
glands intended to insure a full change of all the starch taken into the stomach. 
At present, I cannot admit that its action on fatty substances in digestion is 
proved.''^ — Medical Times, May 31. 



MATERIA MEDICA AND PHARMACY. 

10. On the varieties of Cod-Liver Oil. [M. Donoyan, Esq., has communicated 
to the Dublin Medical Press (Oct. 22, 1851), the following interesting observa- 
tions on the varieties of cod-liver oil.] 

The great difierence observable in the cod-liver oils of commerce renders it 
important to inquire what are the opinions of those who have had the best 
opportunities of estimating the therapeutic powers of the different kinds. I 
was the first person in this country that manufactured the oil for medicinal 
purposes, and was at that time (several years since) under the impression that 
to produce it as free as possible from taste and colour was a chief object, not 
on account of any superiority of curative power, but because I conceived that 
by so doing the repugnance of persons requiring its use would be greatly 
lessened. According to evidence presently to be adduced, it appears that ad- 
vantages of greater importance are obtainable by a sacrifice of those which merely 
relate to facility of administration ; the medical efficacy is the legitimate object 
to which attention should be directed : I shall therefore confine myself to show- 
ing that the weight of evidence is in favour of the light brown or deep golden- 
coloured cod-liver oil. 

In this country we have but two designations — viz., the " pale'' and the " light 
brown or deep golden-coloured there are many varieties in shade of each ; 
but they may be all resolved into those denominations ; and with regard to 
their relative values as medicinal agents, there seems to be no difierence of opin- 
ion amongst competent judges. 

Dr. Schupman, who successfully treated two cases of paralysis of the lower 
extremities with cod-liver oil, observes that " this remarkable power belongs 
only to the brown-coloured oil, the light-coloured losing much of its virtue in 
its purification." (De Jongh, p. 77.) Richter also declares " the brown-co- 
loured to be the most powerful, whilst to the light he denied any power whatever." 
(Ibid. 79.) De Jongh has published his researches on the comparative medici- 
nal powers of the three kinds of oil, from which it appears that the times 
necessary for the performance of the cure were very difierent. Thus five months 
and a half were necessary for the cure of rickets with the paler oils, while the 
same cure was afiected in three months and a half by the brown oil : and chronic 
rheumatism required three months and a half for cure with pale oil, and one 
month and one-third with brown. These inferences were drawn from a great 
many cases ; and analogous results were obtained in other diseases. De Jongh 
concludes that "we may ascribe to it (the brown oil) more powerful healing 
properties than to the other two kinds (the pale kinds), (p. 157.) He adds, 



224 



Progress of the Medical Sciences. 



[Jan. 



" it is therefore fair to assume that the brown cod-liver oil owes its greatest 
power to the biliary matter and butyric acid which exist in it in much larger 
proportions than in the lighter coloured oils." (p. 160.) 

The conclusion to which Dr. Bennett, who has paid great attention to this 
subject, has arrived is that amongst the various kinds of cod-liver oil, the "least 
beneficial is the white." (Bennet on Cod-liver Oil, p. 175,) Elsewhere he says 
that, being present at the half-yearly meeting of the Medical Association of 
Wirtemberg, he examined the three kinds of cod-liver oil presented to the 
meeting — first, light straw colour almost white ; second, golden colour ; third, 
deep chestnut brown : " of these the second or deep golden yellow colour is for 
the most part used medicinally throughout Germany." ^ (p. 20.) _ 

Some patients inconsiderately complain that the cod-liver oil with which they 
are supplied has a " very fishy taste and smell." It is not wonderful that fish 
oil should have a fishy taste and smell. But this leads to the disclosure of a 
miserable fact that, in commerce, we occasionally meet with a so-called cod-liver 
oil which is not subject to either of these complaints, being in fact derived 
from poppy seeds, colza seeds, or from the olive by heat and expression ; it is 
thin, limpid, and pale ; and its vegetable origin is discovered by the fact, that it is 
entirely solidified by an acid solution of nitrate of mercury. On this subject, 
Dr. Bennett says, " when first introduced into the infirmary, neither the physi- 
cians, the apothecary, nor the druggists of the town were enabled to distinguish 
cod-liver oil from other kinds of oil. On one occasion, I found all the patients 
takino- linseed oil instead of it ; and it is a fact worthy of observation that 
several practitioners who employed it at that time gave it up as inert." Well might 
they do so* 

It is thus that many a valuable remedy has fallen into disrepute by the use of 
substitutions. An oil has been of late ofi'ered for sale by persons who purchase 
up the livers, intestines, and ofi'al of every sort of fish collected from the fish 
markets ; they melt them, and render the oil pale and clear by various devices. 
It may also be observed that much of the so-called cod-liver oil is derived, not 
only from " the livers of difi'erent kinds of fish, but from the fat of porpoises 
and other marine animals." (Quoted by De Jongh from Konow.) * - 

When I commenced the manufacture of cod-liver oil, I caused the gall bladder 
which adheres to the liver of the fish to be removed in each case, and gave a 
direction to that efi'ect in my published essay ; for at that time the beneficial 
effect of the bile was not suspected. Of late, I have discontinued this practice, 
it being rendered probable by several considerations, adduced by writers on the 
subject, that the biliary ingredient in the oil is of use. 

The commercial pale oil is obtained by various objectionable processes ; one 
of the most general methods is the putrefaction of the livers (Mack quoted by 
De Jono-h), a sufficiently disgusting mode of proceeding. This is the method 
adopted°in Newfoundland, the motive being not colour, but the extraction of a 
greater produce of oil. Pennant thus describes the process : " they take half a 
tub and boring a hole through the bottom, press hard down into a layer of 
spruce boughs, upon which they place the livers, and expose the whole appara- 
tus to as sunny a place as possible. As the livers corrupt, the oil runs from 
them." The oil obtained from corrupted livers surely ought not to be used as 
a medicine ; in another place I have pointed out the possible ill-consequences 
of such a practice. (See Dublin Medical Journal, 1845.) 

Another method of procuring the oil pale is to boil the livers in water until 
the oil be separated, which will then float, and may be skimmed off. Those 
physicians who attribute the virtues of cod-liver oil, or any portion of them, to 
the presence of iodine in some obscure state of combination, or to the bile of 
the fish, as many at present do, would consider that, by the action of water, 
the oil may be deprived of much of its virtue ; accordingly, De Jongh observes 
that the opinion is pretty generally received that " the pale contains no iodine," 
and that the presence of the latter is confined to oil of deeper colour. 

A third method of procuring pale cod-liver oil is by subjecting it to the 
operation of chemical agents. Dr. Richter of Wiesbaden on this subject observes 
that oil rendered pale by chemical means " has a very weak fishy smell, is 
similar in appearance to olive oil, and is disposed of in commerce as the only 



1852.] 



Materia Medica and Pharmaq/. 



225 



pure oil, but is never used internally in Sweden, and is there considered inert." 
(Quoted by Dr. Bennett.) 

One of the chemical processes is to mix the oil with bones burnt to blackness 
and powdered : the bones being afterwards separated by the filter. The oil is 
thus deprived of its colouring matter, and much of its smell. Who will venture 
to affirm that its medicinal powers are not thus impaired? 

Another process is exposing the oil, in thin broad layers, to the action of the 
sun and air for months. The chemical agency of light in this case is not prob- 
lematical ; the constitution of the oil is certainly changed, and who will deny 
that it may be injuriously altered. But some manufacturers, impatient of the 
tedious process of bleaching by sun-light, adopt the more speedy method of ex- 
posing it to the action of chlorine. On this last method, the German translator 
of De Jough says — " It is not always because the pale oil appears to contain 
less powerful qualities, but far oftener owing to the frequent deceptions to which 
those who employ the pale oil are exposed. It is often the common south-sea 
oil, or the seal o'il of commerce artificially blanched. Meebold remarks that 
nearly all the white oil of commerce is blanched by chlorine, by which it is 
rendered not only less powerful, but also equally unpleasant to take." (Ger- 
man translation of De Jongh by Dr. Carey, p. 125.) 

On all the foregoing accounts, I conceive that injury is inflicted on the public 
by this and other kinds of medical cookery, and that physicians should dis- 
courage it. When it is discovered that attempts are made to improve upon 
Nature by surreptitious and perhaps detrimental means, it appears expedient 
that the article should be supplied to the public of the colour recommended by 
those physicians who have most employed it in their practice ; and even if this 
colour presented no other advantage, it will at least be a guarantee that the oil 
has not undergone an}^ injurious treatment. Cod-liver oil of a deep rich golden 
colour must possess all the advantages of that important medicine, beside being 
in the state which protects it from suspicion. 

An opinion prevails that genuine cod-liver oil may be distingnished by its 
property of producing a fine crimson colour when triturated with concentrated 
sulphuric acid. There can be no test more deceptive. Several fish oils pos- 
sess the same property ; but above all, the test fails by affording the desired tint, 
even when the oil is mixed with a large proportion of vegetable oils. 

11. On tlie Medical Employment of Extracts of Flesh and Blood. By MM. 
Breslau and Mauthxer. — Dr. Buchxer states, that such great benefit has 
been derived from the employment of Dr. Breslau's exiractnm carnis, as a 
remedy in the diseases of exhaustion in children, that it ought to find a place 
in the materia medica. Fresh ox-flesh, freed from fat, first finely chopped up, 
and then well beaten in a stone mortar, with a little cold or lukewarm distilled 
water, is afterwards submitted to a good press. The cake is again similarly 
treated, and when the juice is thus pressed out of it, it may still, when seasoned, 
be advantageously employed as food. The juice, reddish in colour, is immedi- 
ately heated sufl&ciently to coagulate the albumen, and is then evaporated in a 
water-bath to the ordinary consistency of an extract. As ordinary ox-flesh 
contains only 1 in 1000 of Kreatin, while that of the heart, according to Gre- 
gory, contains from 1.37 in \A\, this is the part employed by Dr. Breslau at the 
chief apothecary establishment in Munich. The extract is of agreeable odour 
and taste, and is easily soluble in water, when it reddens litmus. By the addi- 
tion of caramel to the juice, the taste and consistency of the extract is much 
improved. 

In the exhausting diseases of children, Dr. Mauthner strongly recommends his 
extractum sanguinis bovis. Fresh blood caught from the slaughtered animal is 
passed through a sieve, and then evaporated in a water-bath to dryness, rub- 
bing it up into powder when cold. From 10 to 20 grains are given per diem 
in a little water, the solubility being increased by the addition of a few drops 
of spirit of wine. Dr. Mauthner has now employed it with great success in 
about twenty cases, several of which were reduced to an apparently desperate 
condition before commencing with it. Four cases are related as examples. 1. 
A girl, set. seven, had suffered from catarrhal diarrhoea during eight days, which 



226 Progress of the Medical Sciences. ' [Jan. 



completely reduced her. She took 5j of the extract daily, from the 28th of 
August to the 10th of September, when she left quite well. 2. A girl, set. 
twelve, was reduced to a mere skeleton by diarrhoea ; and after being treated 
by various means, and constantly getting worse, she commenced the extract on 
the 8th of September, and was quite cured by the 27th. 3. A child, set. seven, 
very liable to scrofulous ophthalmia, and now reduced to the lowest point by 
diarrhoea supervening on hip-joint disease, continued the extract from the 8th 
to the 22d of September, when he left the hospital cured as regards his immedi- 
ate cause of exhaustion. 4. A child, set. four, suffering from hectic and mani- 
festing bronchophony, had ajistula ani form, and was reduced to a complete 
state of anaemia. He recovered by continuing the extract from the 1st to the 
12th of September. It is by no means a disagreeable remedy ; and a child will 
take it when it will not take, or rejects, ordinary medicines. It does not appear 
in the stools, scarcely a trace is found in the urine, and it is never vomited. 
It is especially useful in what Dr. Mauthner terms exhaustio scrofulosa, and 
the child will take it much better than the ol. jecoris. It is of no use in the 
acute marasmus and anaemia of young infants, due to bringing up by hand, 
who are brought to the hospital during the last days of their wretched exist- 
ence. — Buchner's Rejpert., No. 19, p. 90 ; Journ.fur Kinderkrank., xvi., p. 56. 

12. Injurious Effects of Camphor administered in an Enema. — M. Aran has 
communicated the following case to the Medical Society of Parisian Hospitals, 
and has been induced to do so because the dose that he has here employed, and 
which had given rise to serious symptoms, is that which is recommended in the 
formulae of modern therapeutic works. 

A young woman, aged twenty-seven years, was admitted into the Necker 
Hospital under the care of Dr. Aran, suffering from nervous symptoms of an 
anomalous character, neither epileptic nor hysterical, and for whom, after 
having employed various tonics and antispasmodics, the author prescribed an 
enema containing a drachm (four grammes) of camphor. Two minutes after 
the administration of the enema, the patient complained of a sense of fainting, 
and pain in the abdomen ; she was then seized with a violent convulsive attack 
attended with loss of consciousness, foaming at the mouth, contortions of the 
limbs, the head bent backwards, the face blue, coldness of the extremities, 
feebleness of the pulse, and extreme distress in respiration. This paroxysm 
lasted twelve or fifteen minutes. The patient recovered consciousness by hav- 
ing cold water dashed on her face, but she still complained of a sense of suffo- 
cation, and s'H.id she was dying. After having administered a purgative enema 
to remove the camphor, stimulating frictions were employed on the limbs, and 
strong infusion of coffee was given from time to time. Nevertheless, the dis- 
tress in the breathing, and the feebleness of the pulse, became augmented. 
The patient was then laid on a bed ; the body was covered with sinapisms 
sprinkled with solution of ammonia, a stream of cold water being poured upon 
the head, while at the same time a strong infusion of coffee was given at inter- 
vals. These affusions calmed the agitation and anxiety of the patient, although 
she still felt the same oppression of breathing. The pulse rose a little ; the skin 
had become reddened by the sinapisms, although she was not conscious of their 
application. About an hour after the first occurrence of these anaesthetic 
symptoms she was placed in a warm bed, and covered with warm clothing, con- 
tinually renewed ; she scarcely felt the warmth. The coffee was now rejected 
by vomiting ; a cordial draught with tincture of canella was then substituted. 
The skin became very hot, while the face and feet remained cold. By perse- 
vering in this treatment, the patient was placed out of danger four hours after 
the first appearance of the symptoms of poisoning. — London Medical Gazette, 
September 26, 1851. 

13. On the Filix Mas in Tcenia. — Professor A lbers, while noticing the great 
success that has attended the use of kousso in England, observes, that he has 
derived so much benefit from the employment of the extractum filicis maris 
cethereum, that even putting aside the difference in price, he does not think the 
kousso ought to supplant it. For two or three days the patient lives sparingly, 



1852.] 



Materia Medica and Pharmacy. 



227 



and the day before he commences the filix he takes a dose of Glauber salts. 
Next morning thirty grains of the extract are given, and the dose is repeated 
in one hour, a dose of castor-oil being given one or two hours yet later. In 
from six to eight hours after the first dose of extract, the worm is expelled ; and 
in only two out of about one hundred cases has Dr. Albers known this prompt 
action to be wanting. In one of these the dose required to be repeated, and in 
the other to be much increased. 

Much of the efficacy of the extract depends upon its efficient preparation. 
Only the fresh root should be used. Collected in May or June, it must be ma- 
cerated in ether for several days, the infusion being frequently shaken. This 
extract is more easily taken than is thekousso. — Brit, and For. Med.-Chir. Rev. 
Oct. 1850, from Casper's Wochenschrift, 1850, No. 31. 

14. On the Mineral Waters of Baden-Baden. — By Dr. Sheridian Muspratt, 
F. R. S. E., &c., Professor of the College of Chemistry, Liverpool. (Read before 
the Royal Society of Edinburgh, and communicated by the Author to the 
American Journal Med. Sci.) 

Baden is embosomed among hills, forming an offset of the Black Forest range, 
and seated on the banks of the Oos, an insignificant stream, which once, how- 
ever, formed the boundary line between the Franks and Alemanni. It is famous 
for its beauty, but more so for its mineral springs, the most renowned in. 
Germany, which were known to, and appreciated by the Romans, who fixed a 
colony in Baden, and called it Civitas Aurelia Aquensis. These springs are very 
much frequented, and their water is used internally and externally in all kinds 
of diseases, more especially for liver, mesenteric, and uterine complaints or 
obstructions : in fact, in 1845, nearly 40,000 persons resorted to them. The 
undoubted benefit derived from mineral waters in various diseases attracted 
the attention of chemists, from a very early date, to the composition of medici- 
nal springs. A great number of analyses have been made of such waters, but 
most of them are imperfect, owing to the crude state of analytical chemistry 
when they were performed. 

As yet, our speculations regarding the part played by each constituent of 
mineral waters are very vague, often in consequence of want of system in the 
arrangement of the various elements. So long as results are not tabulated 
according to some rule, it is impossible for the physician to institute a correct 
comparison, or to be able to judge upon which ingredient their effect mainly 
depends. There are thirteen thermal springs in Baden, which gush out of the 
rock at the foot of the Schneckengarten. A fine temple-like structure is erected 
over the Ursprung — principal spring — one of the hottest and most copious 
sources. The massive vault which encloses the spring is of Roman construction . 

It is strange that there is no English work wherein an analysis of the waters 
of Baden-Baden is given. In order to have this deficiency remedied, I think it 
proper to furnish your Society with the analysis, which may prove interesting 
to others further pursuing the subject. 

Qualitative Analysis of the Water. — The water as it flows from the Ursprung — 
principal spring — has a temperature of 67.5° C. = 153.5° F., the temperature of 
the surrounding air being 75° F. ; it is clear, and possesses a very faint animal 
odour, a trace of sulphide of hydrogen (?) and does not affect vegetable colours ; 
it has a slight saline, or more properly speaking, a brothy taste. 

The annexed experiments showed the several ingredients of the mineral 
water. When the water was boiled for some time a small white crystalline pre- 
cipitate subsided. The qualitative analysis was, therefore, divided into two 
parts. 

1st. The analysis of the crystalline precipitate. 
2d. The analysis of the substances in solution. 

1st. The precipitate was treated with hydrochloric acid, which dissolved it 
all with effervescence, proving the presence of earthy carbonates and the absence 
of sulphate of lime. A portion of the hydrochloric solution treated with sulpho- 
cyanide of potassium, gave a faint red colouring, indicative of iron. The pre-' 
cipitate did not contain any magnesia. 
No. XLY.— Jan., 1852. 16 



228 



Progress of the Medical Sciences. 



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2d. Analysis of the Substances in Solution. — A portion of the liquid filtered 
from the crystalline precipitate when evaporated to dryness did not effervesce 
with hydrochloric acid, proving the absence of alkaline carbonates. 

A second portion of the liquid afforded on the addition of nitrate of baryta, a 
slight white precipitate, insoluble in hydrochloric acid, indicating sulphuric 
acid. 

A third portion of the solution gave, with nitrate of silver, a copious white 
precipitate, easily soluble in ammonia, proving the presence of chlorides and the 
absence of iodides. 

A forth portion of the liquid was treated with hydrochloric acid and evapo- 
rated to dryness over a naked lamp ; on treating the residuary mass with water 
an insoluble part remained — silicic acid. A fifth portion of the liquid with the 
chloride of ammonium and oxalate of ammonia, gave a white precipitate of 
oxalate of lime. The filtrate from the oxalate of lime precipitate was divided 
into two portions ; one gave slight indications of magnesia when treated with 
ammonia and phosphate of soda ; and the other portion when evaporated to 
dryness, yielded a residue, which, when treated before the blowpipe, coloured 
the flame intensely yellow, and gave, after being heated to redness with an 
alcoholic solution of bichloride of platinum, indications of potassa. 

By separating the carbonate of lime and evaporating the filtrate nearly to 
dryness, cubes of chloride of sodium appeared in company with silky crystals 
of sulphate of lime formed by double decomposition. If the liquid be evapo- 
rated to dryness, the residue on exposure readily deliquesces, showing the 
presence of chloride of calcium. The substances present, and their respective 
amounts, in the imperial gallon, are the following : — 



Grains per Imperial Gallon. 

Sulphuric acid 3.487 . . 3.493 

Chlorine 94.064 . . 93.991 

Silicic acid 2.947 

Carbonic acid in combination with calcia . . 6.240 
" " protoxide of iron 0.514 

Sodium 52.152 

Potassium ......... 7.182 

Calcium 4.000 

Calcia (lime) insoluble 7.943 

Magnesia 1.749 

Protoxide of iron 0.842 

Alumina, phosphate of lime, organic matter, &c. Mere traces 



181.120 



Kesidue given by direct experiment 181.129 



As the qualitative analysis proved the sulphuric acid not to be in combination 
with calcia (lime), the above bodies are hereafter tabulated in the exact state 
in which they exist in the water, thus : — 

Grains in the Imperial Gallon. 



Chloride of sodium 132.644 

Chloride of p^otassium 13.720 

Chloride of calcium 11.040 

Sulphate of magnesia 5.236 

Carbonate of calcia (lime) 14.184 

Silicic acid . . • 2.947 

Proto-carbonate of iron 1.356 

Alumina, phosphate of lime, organic matter . . Mere traces 



181.127 

Specific gravity of the water =1.00284 

Cubic inches of carbonic acid, per gallon . . . 4.500 



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Medical Pathology and Therapeutics. 



229 



The only analysis I can find of the Baden-Baden water is by Kolreutcr.* He 
gives the amount of each constituent in sixteen ounces of the water. I append 
his results calculated to the imperial gallon : — 



Chloride of sodium 
Chloride of magnesium 
Chloride of calcium 
Sulphate of lime 
Carbonate of lime 
Silica . 

Extractive matter 



160.00 
2.50 
17.50 
30.00 
16.60 
3.30 
0.50 



230.40 (?) 

His total amount of ingredients appears to be a great deal too much ; more- 
over, he gives sulphate of lime as one of the constituents, and finds no chloride 
of potassium. 

From the preceding analyses, it appears the principal ingredient is chloride 
of sodium, hence it belongs to the class of saline waters. 

15. A New Method of Preparing Powders for use in Medicine. — Wittke, of 
Erfurt, recommends a new and very useful form of powder. Tinctures, as is 
well known, generally possess the most active properties of the drugs from 
which they are prepared, but the amount of spirit they contain often renders 
their employment inadvisable ; Wittke, therefore, mixes tincture of hellebore, 
of cinchona, &c., with an equal quantity of sugar, evaporates to dryness, and 
powders the residuum. In this manner he succeeds in concentrating, in a very 
small bulk, the active portion of a very large quantity of the drug, and he pre- 
scribes the powder as saccharized cinchona, &c. These preparations bear 
some analogy to conserves, over which, however, they have a great advantage 
in being free from mucilage, vegetable albumen, and other inert matters. — 
Duh. Quart. Jour. Med. Sc., Nov. 1851, from Vierteljahrschrift fur die praktische 
Eeilkunde, Prag. 1851, Bd. 3. 



MEDICAL PATHOLOGY AND THERAPEUTICS AND PRACTICAL 

MEDICINE. 

16. On some of the Histological Characteristics of Malignant Growths. — By 
Prof. Albers, of Bonn. 

1. No form of growth other than the malignant consists so exclusively, even 
to the acquisition of a large size, in cell-formation, all non-malignant ones con- 
taining a great abundance of fibre-formations. It may be objected that epithelial 
tumours consist of cells, and yet remain innocent. It is to be observed, how- 
ever, that such tumours always remain small, and have not proved so generally 
innocent as the polypus and fibroid. Epithelial tumour, too, frequently re- 
lapses, and is sometimes as destructive as cancer itself. Among other innocent 
tumours, the fatty especially exhibits cells, but the regular fibrous network, 
which is also present, essentially distinguishes them from all malignant tumours. 

2. In innocent growths the cells decrease with the duration of these, while 
in malignant ones they increase. At the commencement of the so-called 
tumours of the cellular tissue, among the predominant fibres, cells are to be 
seen, which at an older date are entirely absent; and the same is observed in 
polypous and fibroid. In malignant tumours a great number of fibres are 
found at first; but the longer the tumours exist and the larger they become, the 
more completely do such fibres disappear, leaving the cells as the sole histolo- 
gical element. 

* Simons' Heilquellen Europa^s, Berlin, 1839, p. 22. 



230 



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3. Certain peculiarities are observed in these cell-formations, among which 
maybe mentioned the incomplete formation of the greater part of the cells, 
when the tumour is old and large, and especially in the case of relapsing and 
secondary formations. The cells exhibit either a different form, an unequal 
size, or an irregular degree of development. The equal development of the 
structural elements of polypous, fibroid or fatty tumour, furnishes an entirely 
different general impression from that derived from any kind of malignant 
tumour. 

4. Besides the incompleteness and irregularity of the development of cells 
in malignant growths, they are found in these to undergo a rapid disintegra- 
tion, examples of which, though more frequently met with in the older tumours, 
are not wanting in the younger ones, showing the retrograde changes- which 
are taking place. The elements proving this, are granules, granular bodies, 
and granular cells ; and these are to be found in a greater or less number in 
every cancerous tumour proportionate to its age. If, on the other hand, we 
consider the regular and unchanged condition of the cells in fatty tumours or 
polypus, in which scarcely any granular bodies or cells are found, it becomes 
certain that the duration of the life of a cell is much longer in innocent than 
in malignant tumours. 

5. Malignant tumours are remarkable for the rapidity of their cell growth. 
In a feAV days an entire lung may undergo tubercular transformation, or a can- 
cerous tumour acquire double its size. A relapse may occur in five or six days, 
and a few days later may attain enormous dimensions. No innocent tumour 
comports itself thus. 

6. In malignant swellings we always find a more abundant juice, which flows 
out on pressure, and contains some of the elements of the disease, as the cells, 
and the same fluid blastema is obtainable from tubercular lungs. When fluid 
is pressed out from a polypus, it contains no cells or fibres, or very few, while 
in that obtained from cancer there are numerous cells in every stage of develop- 
ment. It follows from this, that the textural connection in the malignant 
tumour is always looser, and the proportion of fluid blastema always larger, 
than in the innocent ; and that these slightly connected elements are easily 
separable, and are incapable of the degree of development observed in the in- 
nocent ; being, therefore, endowed with a shorter duration of life than these. 

It results from the above observations, that there is less mVo!? energy and 
durahility in malignant growths, as is shown by the fewer stages of develop- 
ment they are capable of ; and by the great disposition of the cells to terminate 
their life, and to pass into granular bodies and granule-cells. This retrograde 
course explains the inordinate increase of cells, just as we see an immense 
reproductive power in animals placed low down in the scale. The lower its 
vital energy sinks, the more rapidly does the growth increase, so that the 
second or third relapse takes on a much larger and more rapid development 
than did the original tumour — a point well deserving the attention of the ope- 
rator, lest, by his interference, he lowers the amount of vital energy, and 
hastens death more rapidly than it would have occurred had the case been left to 
nature. It is to this diminution of vital activity, that the peculiar softening of 
these tumours is due. In the softened mass are found the elements of the de- 
generated structure with incompletely formed pus globules ; and when the 
vital power is increased, and, as in tubercle, a stationary condition of the dis- 
ease produced, a more complete pus formation takes place. — CanstaU's Jahrb., 
1850, v., 248. 

17. On the Local and General Nature of Tumours. — The distinction of tumours 
into malign and benignant, so long employed by practitioners, is an irrational one 
according to M. Lebert, and the chief cause why the study of these productions 
has made so little useful progress. The grand question, on the contrary, which 
should occupy attention, for the sake of prognosis and treatment, is their local 
or general nature. 

To commence with cancer : this disease is undoubtedly one of the whole 
economy. AVhen we study cancer in a large number of patients, and in all its 
principal varieties, we become convinced that the first appearance of the disease 



1852.] 



Medical Pathology and Therapeutics. 



231 



is the expression of a general diathesis. In whatsoever part of the body cancer 
may be first developed, it has a tendency to propagate itself from the original 
point ; it also gives rise to secondary deposits of the cancerous matter, and the 
general infection always progresses until life becomes extinct. 

Hence M. Lebert, with many surgeons of the French school, thinks it is not 
sufficient to remove the local complaint early and in the most absolute manner. 
It will return at a later period, either in the original place, or from secondary 
deposit, and the attentive observer remains convinced that the whole mass of 
the blood has been tainted, as after certain modes of poisoning. 

Numerous aifections have been confounded with cancer, but careful examina- 
tion reveals essential differences between the two classes of maladies ; and the 
more we examine, the more shall we be convinced that the essential charac- 
ters are not isolated or exceptional artifices of the scalpel, or tricks of the micro- 
scope, but that the organic development, progress — the pathological physiology, 
in a word — point out lines of demarcation which, in their turn, indicate 
essential modifications of treatment. Still, although the difference between the 
local and the general malady be so great, it must not be forgotten that the va- 
rious local affections which have hitherto been confounded with cancer, present 
very remarkable differences in their progress and gravity. 

Let us pass rapidly in review accidental products, taking their local or gene- 
ral nature as basis. In the first group we have encysted tumours of the skin, 
erectile tumours, fatty, fibrous, and cartilaginous tumours. Here the manifes- 
tation is confessedly local, yet how many differences do we find ? Encysted 
tumours originating in the sebaceous glands of the skin, are undoubtedly in- 
capable of infecting the economy, but they may become multiplied to an extra- 
ordinary degree. I saw an old soldier with more than eighty of these tumours 
on different parts of the body. In another case, these sebaceous tumours had 
perforated the bones of the skull, and caused death; yet the disease had never 
attacked any other structure than the one originally implicated. Its severity 
did not depend on the economy becoming involved or tainted. The same remark 
applies to erectile tumours. These often apparently change in consequence of 
repeated irritation, and surgeons then say that " the tumour has degenerated 
into the fungus hematodes or cancer yet M. Maunoir demonstrated many years 
ago, in the most peremptory manner, the essential differences. Erectile tumours 
may kill, but they never degenerate so far as to affect the constitution. Fatty 
tumours may likewise inflame, ulcerate, and assume a threatening appearance ; 
but it would be much more in accordance with sound reasoning ^to compare 
these changes with the inflammation and ulceration which take place in other 
parts of the body, rather than have recourse to an hypothesis of degeneration, 
the existence of which nothing proves. 

Fibrous and cartilaginous tumours present themselves under the same circum- 
stances of localization as those already noticed. A woman may have several 
fibrous tumours in her uterus, yet this does not prove that the disease is con- 
stitutional; while its progress and effects are so different from those of cancer, 
that the most superficial observer will seize the distinction. 

Hypertrophy of the lymphatic and mammary glands has often been, and still 
daily is, mistaken for cancer ; but it is impossible to find more clearly marked 
the difference between a local and a constitutional tumour than oh comparing 
partial hypertrophy of the mammary gland with cancer of that organ. In the 
former affection, we may have one or many tumours in the gland ; but secondary 
tumours never supervene. The swelling of the axillary glands is merely sym- 
pathetic. The general health remains intact. In partial hypertrophy, the 
tumour is well defined, and composed of glandular lobes or lobules, in which the 
microscope displays the terminal coeca of the gland. In cancer, the tumour is 
more diffused ; the normal elements of the gland are destroyed, and the charac- 
teristic cellules of cancer occupy the interior of the tumour. 

Fibro-plastic tumours may sometimes lead to doubt, both on account of the 
march of the disease, and from the fact that it often returns after extirpation. The 
relapse is particularly liable to occur after operation for fibro-plastic tumours of 
the bone. Here, however, the relapse is a local effect; being rather a continuation 
than a reproduction of the original malady. The fact is, the periosteum is much 



232 



Progress of the Medical Sciences. 



[Jan. 



more extensively diseased than would appear after examination, and the germs 
of the disease are thus left behind ; but in no case do secondary deposits occur 
at a distance from and independent of the original tumour. 

The last class of diseases to be noticed are those fungoid ulcers found in the 
skin, the tongue, lips, etc. These have always been confounded with true 
cancer. It was, indeed, remarked by the older surgeons, that they were often 
cured, and it was hence concluded that cancer of the skin was milder than any 
other species. But this is a serious error, for true cancer is just as inveterate 
and malignant when it attacks the skin as any other organ. 

About six months ago, M. Ecker in Germany, and M. Lebert in France, de- 
monstrated that a great portion of those cutaneous or mucous ulcers were merely 
alterations of the epidermis of the glandules, or of the dermis itself. In true 
cancer, we have new products; in these cancroid tumours we have exaggeration 
of normal structures ; the progress of cancroid tumours is different from that of 
cancer, and when removed by the knife freely, they either never return, or are 
reproduced on the original site. They are mainly composed of epidermis or 
epithelium, are diffused in the surrounding tissue, and hence subject to relapse 
after incomplete extirpation. As for secondary tumours, however, relapse oc- 
curring at a distance from the primary tumour, or constitutional infection, M. 
Lebert has met Mviih nothing of the kind in more than 100 cases of cancroid 
disease, twenty of which were examined after death. — Med. I'imes, 19ih Juli/, 
1851, from Gazette Med. de Paris. 

18. Cancroid GroiotJis. — Dr. Bennett made some interesting remarks at a 
meeting of the Physiological Society of Edinburgh, on the existence of a class 
of tumours to which the name of cancroid was applicable, inasmuch as they 
very closely resembled true cancer in their more apparent characters, and often 
also in their tendency to a wide-spread distribution, while structurally they 
were very different from the ordinary types of cancerous growths. He thought 
it a matter of the utmost importance, that structures which differed so much 
from each other should be studied with regard to their symptoms, progress, 
liability to return after excision, and susceptibility of undergoing spontaneous 
disintegration, instead of being, as they are at present, all confounded together 
under the term malignant. It had been stated by Miiller that enchondroma 
was not liable to return, but he had recorded a case in his work "On Cancerous 
and Cancroid Growths'^ (Obs. 48), where a cartilaginous tumour of the humerus 
had been amputated, and yet where a disease apparently similar had returned 
in the axilla and neighbouring parts, and destroyed the patient. Unfortunately, 
this secondary growth had not been examined microscopically, so that, strictly 
speaking, it had not yet been clearly demonstrated that enchondroma was ma- 
lignant, although the casein question rendered this probable in some instances. 
He considered there could be no doubt that epithelial growths were occasion- 
ally susceptible of being propagated to the neighbouring glands, of ulcerating 
and producing death exactly in the same manner as tumours really cancerous. 
He believed that, as exact observations extended, other forms of structure dif- 
fering from cancerous, cartilaginous, or epithelial growths, may be found also 
malignant in the usual acceptation of that term. In proof of this, he related 
two very remarkable cases, in both of which death had been occasioned by 
apparently an encephaloma, in one instance attacking the lung and in the other 
the ovary. 

The first case was recorded in Obs. 43 of his work "On Cancerous and Can- 
croid Growths." It was that of a young woman, who had a fungous tumour of 
the leg, which was amputated by Mr. Norman, of Bath, the stump healing 
without accident. Dr. Davis of that city had sent Dr. Bennett a portion of the 
tumour, the structure of which is described and figured in the work referred to. 
It consisted "of fusiform corpuscles in different stages of development, mingled 
with naked nuclei, a multitude of molecules and granules, and a few blood 
globules. Some corpuscles were of oval form, others elongated and caudate, 
others truncated at one end, or spindle-shaped. None exceeded the l-200th of 
a millimetre in breadth; and in length they varied from 1-lOOth to the l-25th 
of a millimetre. Several contained a minute granule, about the l-500th of a 



1852.] 



Iledical Pathology/ and Therapeutics. 



233 



millimetre in diameter. On the addition of acetic acid, most of the loose mole- 
cules and granules were dissolved, and a faintly fibrous structure produced, in 
which oval bodies were scattered, varying in their longest diameter, from the 
1-lOOth to the l-50th of a millimetre/' 

The structure in consequence in no way resembled cancer ; yet two years 
afterwards disease of the lung commenced, and she died with all the symptoms 
of cancer of that organ. On examination, an encephaloid tumour of the lung 
M'as found, a portion of which was kindly sent to Dr. Bennett by Dr. Davis, 
who with Mr, Norman attended the case, and on microscopic examination it was 
found to possess exactly the same structure that was previously described as 
forming the tumour of the leg. 

The second case was that of a woman who died of encysted tumour of the left 
ovary, a portion of which was sent to Dr. B. by Mr. Russel of Birmingham. It 
exactly resembled encephaloma, being pulpy in consistence, white in colour, 
and yielding a copious milky juice on pressure. The other ovary presented 
an incipient condition of the same morbid alteration. On microscopic examina- 
tion, it was found to consist of masses of columnar epithelium, which had un- 
dergone more or less of the fatty degeneration, and were loaded with oil gran- 
ules. These were arranged side by side, and frequently presented in the juice 
squeezed from the surface of the growth, a concentric arrangement, which 
would be best understood by examining the drawings exhibited. Associated 
with this epithelium was a multitude of diaphanous bodies, varying greatly in 
size — in some of which oil granules had also accumulated, so that many of them 
presented all the characters of compound granular corpuscles. No trace of 
cancer cells could anywhere be discovered. Of this singular form of growth 
Dr. Bennett had now seen two other examples, both of which had occurred in 
the ovary. 

In conclusion. Dr. Bennett stated that it was only by multiplying such 
observations, and determining, in the first instance, the structure and progress 
of the difierent forms of malignant growths, that we could ever hope ultimately 
to arrive at the mysterious laws which governed their origin and propagation. 
— Monthly Journ. Med, Sci., Nov. 1851. 

19. Ways in which Death occurs. — In a series of able papers, in the London 
Medical Gazette (Feb. 28th, March 24th, April 11th, Aug. 8th, 1851), On the 
Different Ways in which Death Occurs, Mr. B. W. Richardson comes to the 
following conclusions respecting syncope: — 

Syncope may arise from two kinds of derangements in the circulating ma- 
chinery — first, from blood being diverted from the heart ; and secondly, from 
the heart being overcharged with blood. 

The heart does, not depend for its power to act on any nervous agency, but 
simply on the stimulus of blood. The value of the recumbent posture in restor- 
ing animation during syncope, does not rest on the cause (so commonly be- 
lieved), that during recumbency the brain is re-supplied with blood, and so the 
heart with nervous power, but on the fact, that when a person faints while sit- 
ting or standing, the heart fails to do more than to throw its blood over the arch 
of the aorta ; and as this even is not done with sufficient force to ensure a return- 
ing verkous current in opposition to gravity, the whole of the blood is allowed to 
accumulate in the vessels below the heart. But the patient at this point falls, 
or is laid down, with the upper part of the body lowest, the position of the 
ascending venous currents is thus entirely changed, the returning blood gravi- 
tates into the heart, and the organ, re-supplied with stimulus, starts again into 
play, and animation returns. 

This explanation affords also a key to many pathological phenomena ; thus 
hemorrhages from the lower half of the body are always much more dangerous 
than those from the upper, because in such cases the lower half of the body is 
a running cistern — not a reservoir of blood. 

Syncope, following purgation, or the abstraction of fluids from cavities, is 
induced by the sudden rush of blood that takes place into the unloaded parts, 
the heart being thus as effectually robbed as in hemorrhage. 

Ruptures or wounds of the heart may not be followed by instant death, and 



234 



Progress of the Medical Sciences. 



[Jan. 



this especially holds good if the wound or rupture occurs at the upper part of 
the organ ; because in such cases, as soon as the organ gets so full as to pour 
out its blood through the artificial opening, contraction of the walls of the heart 
begins to take place, which contraction, as it expels the blood through the natural 
channels, closes also the rupture or wound. 

Kupture of the sound heart scarcely ever occurs, except from a severe fall, in 
which the body alights on the feet or breech. Such falls lead to rupture of the 
heart or aorta, by the concussion of falling bringing down the blood that is pass- 
ing through the ascending aorta, in the same way as the concussion produced 
by bringing the bottom of a bottle, containing a fluid or powdered substance, 
sharply on a hard body causes the powder or fluid to sink lower. In this way 
also, aneurism at the root of the aorta is accounted for, as produced by leaping, 
riding, and the like ; here, the concussion, though not sufficient to cause a rup- 
ture, leads to a state next to rupture — viz., dilatation. 

A beautiful provision against these accidents is found in inferior animals, 
where running, leaping, etc., are required, inasmuch as in them the circulating 
currents from the limbs do not enter the heart perpendicularly, but through 
the medium of horizontal vessels, so that no amount of concussion in falling 
upon the feet can overwhelm the heart with an increased flow of blood upon it. 

In syncope during advanced pregnancy, the danger is very great, because the 
recumbent position is of no avail ; for the gravid uterus falling backwards on 
the vessels running to the heart, acts like a ligature around them. 

Syncope in labour never, or at all events rarely, occurs during a pain : this, 
in consequence of the mechanical necessity, that by each uterine contraction a 
large quantity of blood previously contained in the uterus is poured back into 
the general circulation, by which the heart is continually supplied with stimulus. 

Heat, applied to the general surface, will sometimes give rise to syncope when 
the heart is hypertrophied. The syncopal attack is brought on in this case from 
an increased temperature dilating the capillaries, into which the over-acting 
heart forces its blood and empties itself. 

Syncope may occur from the heart being overpowered with blood, and becom- 
ing paralyzed by its own efforts, in the same manner as ordinary muscles are 
sometimes temporarily paralyzed by sudden extreme exertion. Death probably 
arose from syncope so induced, in those experiments on rabbits, where Sir 
Astley Cooper suddenly arrested the flow of blood passing through the carotid 
and vertebral arteries; and cases are narrated in which a tendency to syncope 
has followed the compression of large arteries in the human subject. 

The heart may also be overwhelmed from causes acting on the venous system. 
Thus from the days of Harvey it has been known that, in abstracting blood from 
the arm, the patient often faints on the removal of the fillet. This ensues from 
the flood of nervous blood suddenly released, returning upon the enfeebled heart 
and overpowering it in a greater or lesser degree, just as in transfusion of blood 
after hemorrhage the heart is liable, to be overpowered, if the injected blood 
is thrown into the circulation with too much force. A case is also sup- 
plied to illustrate that a temporary mechanical arrest of the venous circulation 
in the neck may be followed by the same effects on the obstacle being suddenly 
removed. 

Under the head of syncope from derangements at the heart, the effects'of bar- 
riers (as indurated valves, etc.) in the cavities of the heart, and the effects of 
shocks to the heart, are considered. Reasons are adduced to prove that barriers 
on the left side of the heart are most dangerous, and it is suggested that all 
barriers act detrimentally in two ways — first, by opposing the currents of the 
blood, and secondly, by preventing the walls of the heart from approximating 
closely during their contraction, thus rendering the organ unfit to adapt itself 
to various quantities of blood. 

Among the causes which act on an obstructed heart to produce syncope, exer- 
tion is placed first by Mr. Richardson ; and the doctrines of Dr. Latham concern- 
ing shocks to the heart are dwelt upon. It is shown that the cause why the 
heart never gets over a severe shock, as described by Dr. Latham, rests in the 
fact that the heart can never rest after the shock, and so never regains full 
power. It may play on, but its nice equilibrium is lost. 



1852.] 



Medical Pathology and Therapeutics. 



235 



Exhaustion of the body, and sudden changes of position, are also dwelt upon 
as common causes of syncope during the existence of obstructions at the heart. 
And lastly, an opinion is expressed, that in some states the blood during life, 
in the course of agitation against the valves of the heart, may deposit its fibrine. 
And that in the event of an indurated valve being present, a fibrinous coagulum 
may be suddenly deposited upon it, of suflBcient size to arrest the play of the 
heart, and to bring on fatal syncope. A case illustrative is also supplied. — 
London Journal of Medicine, Nov., 1851. 

20. Experimental Inquiry into tlie Effects of various Animal Matters injected into 
the Blood. — Mr. Millington laid before the Physiological Society of Edinburgh, 
at their meeting of the 19th of July last, the results of some experiments made 
by him to determine the effects of certain animal fluids on the blood. " The 
Society is aware,'' he remarked, " that the formation of numerous small abscesses 
in the viscera, especially in the lungs and liver, and the dangerous constitu- 
tional symptoms that accompany them, so frequently observed after operations, 
parturition, and diseases attended with suppuration, have of late been pretty 
generally referred to the entrance of purulent matter into the blood. But the 
manner in which pus acts in these cases has been much disputed. The numer- 
ous disseminated abscesses of the viscera have been usually explained by the 
mechanical arrest of the pus globules in the capillaries of those organs. This 
opinion is based upon the well-known physiological fact that foreign substances 
entering the blood, and failing to be discharged by the natural emunctories of 
the body, collect, as on a filter, in the capillaries of the lungs or liver, and give 
rise to inflammation there, for their elimination. This view was thought to be 
established by the experiments of Cruveilhier, who introduced metallic mercury 
into the veins of living animals with the effect of producing in the lungs or liver 
numerous small abscesses, each containing a small globule of mercury, accord- 
ing as the metal was introduced into the general or portal circulation. Mr. Lee, 
of London, was the first to call in question this mechanical explanation of the 
modus operandi of pus ; and he has the merit of first demonstrating, by actual 
experiment, that when pus is added to living blood it causes its speedy coa- 
gulation. Mr. Lee expresses the opinion that this effect of pus on blood is 
most marked when the pus is in a fetid state ; and that, when introduced into 
the system, it acts by imparting its own condition to the blood. 

"From a sense of the practical importance of the subject, I have availed myself 
of the extensive opportunities the Royal Infirmary affords for prosecuting an 
inquiry into the pathology of the disease ; and, with the view of guarding against 
many fallacies incident to all investigations of this kind, I have made numerous 
experiments, not only with pus, but with various animal and vegetable fluids, &c. 
It would of course be here quite out of place to enter into the details of all my 
experiments ; and I shall therefore content myself with some general remarks, 
and bring before the Society an experiment performed at 7 A. M. this morning, 
which shows the effects of fresh pus, putrid animal fluid, and bile, on the blood. 
The particulars of the experiment are briefly as follows : The integuments of 
the neck of a living animal having been quickly reflected, one of the jugular 
veins was readily opened, and six ounces of blood were allowed to flow into a 
vessel containing half an ounce of unequivocally fresh pus ; the same quantity 

* of blood was received into a second vessel, containing half an ounce of mode- 
rately putrid animal fluid ; a similar amount of blood was received into a third 
vessel, containing half an ounce of bile. The contents of the vessels were now 
gently stirred with glass rods, and the changes observed in the blood were 
carefully noted. That to which the pus had been added began to coagulate 
almost immediately, in a manner which is quite peculiar, and which I have 
had repeated opportunity of witnessing. Its colour also underwent a change, 
becoming slightly darker. The blood to which the putrid fluid had been added 
became immediately very dark, but did not begin to coagulate until after the 
lapse of some minutes. The blood which had been mixed with the bile was 
quickly changed to a brownish-black colour, but it evinced little tendency to 

. coagulate, though it remained for hours undisturbed. 

*' The Society will see, in the blood placed on the table, a corroboration of these 



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statements. In this vessel, containing the blood to which pus has been added, 
it will be seen that there is a firm crassamentum, which has a peculiar striated 
appearance, owing, as the demonstration now under the microscope shows, to 
the aggregation of the pus globules. The crassamentum often contains in its 
interior small rounded masses, harder than the remaining part of the clot, 
and which, when examined by the microscope, are also found to consist almost 
entirely of pus globules. These effects are characteristically produced when, 
the pus is quite fresh; and, judging from my own experiments, there appears 
no doubt that putrid matters of all kinds retard coagulation ; and that the 
crassamentum formed by blood to which putrid matters have been added, pos- 
sesses certain distinguishing properties to be now noticed. In this vessel, 
which contains the blood to which the putrid animal fluid has been added, the 
crassamentum is throughout of a very dark colour, of uniform consistence, but 
soft and readily broken down by the finger. I have net examined this specimen 
of blood with the microscope, but in others I have frequently been unable to 
detect any change. In some instances I have, however, noticed the diminution, 
and in one case (where the matter added to the blood was extremely putrid) 
the almost entire disappearance of the coloured globules, the colouring matter 
being generally diffused. The colourless corpuscles appeared always unchanged. 
In the third vessel, which contains the blood to which the bile has been added, 
it will be seen that, though only half an ounce of bile was added, it has been 
sufficient to prevent any other than an almost diffluent crassamentum from being 
formed — an effect probably due to the soda of the bile. 

Such being the effects of pus and putrid fluids on the blood, the question 
arises — What hypothesis will give the most natural explanation of the symp- 
toms and morbid phenomena of the disease now commonly known by the name 
of Pyohaemia ? M. D'Arcet has supposed that it is owing to the liquor puris 
becoming purulent after it has reached the lungs ; but M. Sedillot has shown 
that the serum produces no ill effects, when free from putrefaction ; and that, 
when putrid, though local diseases are introduced, they are not of the nature of 
visceral abscesses, but of gangrene. M. Andral has referred this disease to a 
decomposition of the serum and the action of ammonia on the blood, rendering 
it dark and dissolved ; but, when the pus \& fresh, it appears to me very difficult 
to understand how the animal matter can be converted into ammonia. And, 
further, the action of pus on blood is 7iot to render it dark and dissolved, but, on 
the contrary, the crassamentum is firmer than natural. The changes, supposed 
by Andral to be owing to the entrance of pus into the circulation, are the result, 
as I have shown by repeated experiment, of the entrance of putrid matter into 
the blood. A careful perusal of the experiments of M. Gaspard will satisfy any 
one, that putrid matters exert their action principally on the mucous membrane 
of the intestines, giving rise to frequent, dark, and extremely offensive evacua- 
tions, usually attended with decided relief, and in some instances with entire 
disappearance of all the symptoms. The opinion of Rokitansky, that pyohaemia 
is to be referred to a spontaneous change in the blood, is quite untenable, as we 
have no evidence that the blood ever becomes diseased spontaneously. The 
opinion of Mr. Lee, that pus imparts its own condition to the blood, is probably 
nearer to the truth ; but, from a careful observation of the symptoms of the 
disease, from numerous experiments, and from the number of post-mortem ex- 
aminations that I have attended, I have been irresistibly impressed with the 
belief that the effects which follow the introduction of pus into the system are 
such as can be best understood by considering that it acts as a poison ; and I 
think its resemblance to other animal poisons in its mode of action can scarcely 
fail to arrest attention. In many of them we have first a local disease (in the 
case of pyohaemia this may be a stump after amputation, a diseased bone, that 
part of the uterus to which the placenta was attached, &c.), upon which second- 
ary affections supervene in the form of violent inflammation in one or more 
parts of the body. In addition, there is a severe constitutional affection, which 
is characterized by a peculiar fever. 

The opinion that referred the secondary abscesses in the viscera to the me- 
chanical arrest of the pus globules in the capillaries of those organs, was based 
upon the supposition that the globules of pus were larger than the colourless 



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237 



corpuscles of the blood ; but the best proof of the erroneousness of this opinion 
is to be found in the impossibility of distinguishing the pus globules from the 
colourless corpuscles of the blood. M. Sedillot has indeed stated that they 
might be distinguished; but the concurring testimony of all subsequent observers * 
shows that he was mistaken. The experiments of Mr. Gulliver appear to me to 
throw much light on the formation of these visceral abscesses. lie found that 
the introduction of pus into the cellular tissue caused suppuration there more 
surely than foreign bodies of the most irritating kind ; and he expresses the 
opinion that it determines the nature of the subsequent exudation. I have 
witnessed nearly the whole texture of the liver destroyed by abscesses, the re- 
sult of absorption of purulent matter from the interior of the colon ; whilst the 
other organs of the body, after a careful scrutiny, were found free from all ap- 
pearance of the same disease. This, and numerous facts of a similar Mnd, show 
that the lohole of the pus absorbed from the ulcerated intestine never passed beyond 
the capillaries of the liver, but loaf arrested there, not by any mechanical laws, but 
owing to alterations in the vital properties of the blood itself, which determined the 
nature of the subsequent inflammation ; and it is worthy of especial observation, 
that whilst idiopathic inflammation of the same organs ending in suppuration 
is attended with hectic fever, those resulting from the animal poisons are at- 
tended by a fever which is essentially typhoid; and we have good reason to 
think that this peculiarity of the effect of inflammation depends on a deviation 
from the natural state of the vital properties of the blood. 

In conclusion, I would remark that while the history, symptoms, morbid ap- 
pearances, and analogies of the disease with other blood diseases, arising w^ith- 
out doubt from animal poisons, tend to establish the fact that purulent matter 
acts as a poison w^hen received into the blood ; yet w^e cannot conclude, as Mr. 
Gulliver has done, that a small quantity of pus, whether in the blood or in a 
serous cavity, acts like a leaven, and speedily leads to the production of a great 
deal more ; because it has been proved, by repeated experiment, that small 
quantities of pus may be injected into the blood without occasioning any ill 
effects. We must, therefore, conclude that the poisonous action of pus on the 
blood is different from that of any other known poison ; and that it requires, 
for the development of its poisonous action, that it should be introduced into 
the circulation in quantities sufficient to alter the natural state of the vital pro- 
perties of the blood. — Monthly Journ. Med. Sci., Nov.. 1851. 

21. The Affinities and Prophrjlaxis of Variola. — Dr. Dendy recently read an 
interesting and elaborate paper on this subject before the Medical Society of 
London. He first mentioned the obscurity in which the origin of the disease 
has been so long veiled, and then alluded to a sermon, preached in 1722, to 
prove that the devil, w^hen he smote Job with sore boils, w^as the first variolous 
inoculator. In the present day, even after innumerable discussions, there is 
still an extreme discrepancy of opinion regarding the varieties of pock, as vrell 
as the nature, degree, limitation, and value of prophylaxis. The question as 
to the nature of variola and its affinities is intimately connected with that of 
prophylaxis ; for, if it were proved that the several species of pock are but 
varieties of the same genus, the subject of vaccine influence would be ex- 
tremely simple — the substitution of a simple for a severe form of a malady. 
But, supposing an original identity, there arises the question, By what influ- 
ence or transmission has vaccinia lost its epidemic character, while it retains 
its prophylaxis — varicella retaining the former and losing the latter ; while the 
most modified variola retains both, although shorn of its secondary fever ? 
Varicella, from the absence of prophylaxis, is not a disease of much import- 
ance, nor does it belong to the category included in the paper. Bartlett care- 
fully varicellated seven children not previously protected, but failed to produce 
any effect. Bateman and Bayer, however, had a different belief. In its most 
confluent form, however, varicella has never been known to produce variola, 
nor has the latter disease ever been noticed during the prevalence of epidemic 
varicella; and even if inoculation be practised during its prevalence, the vari- 
cella will proceed unchanged ; whereas the synchronous insertion of variolous 
and vaccine matters mutually influence each other to a certain extent. The 



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[Jan. 



succession of crops of varicellous vesicles, and their purely vesicular and uni- 
locular character, even v^^hen confluent or very deeply seated, mark its dissimi- 
larity. The varioloid disease is, however, of much greater importance. This, 
Mr. Dendy said, is the diminutive of variola ; their essence is the same ; and 
he therefore calls it variella; for, although its vesicle may dwindle in its birth, 
or pass at once about the seventh or ninth day, to the crust, yet if its pus or 
lymph in extreme attenuation be used to inoculate M'ith, sooner or later the 
true variolous pustule will be produced. The following is his classification : — 

Variola — Small-pox. 

Variola papularis — Horn-pock. 

Inoculated variola — In a previously vaccinated person. 
Variella — Casual variola in a previously vaccinated person. 
Vaccinia — Cow-pock. 

Vaccinia spuria — The pustule of grease or udder sores, or heterogeneous or 

foul matter, often attended by bullae, rupia, or erysipelas. 
Vaccinella — Imperfect, or abortive vaccine. 

i Lenticular, chiefly in children. 
Conoid, swine-pock. 
Globosa — hives — the closest afl&nity to variola in form, as it has a 
pa,rtial disc ; but none of these produce full variola by inoculation. 
To be capable of transmission and prophylaxis, the pock must be circular, 
umbilicated, and cellular, having a hard base and containing lymph. If such 
be not the case, even during the crusting of the false vaccine, not only variola 
but variella may impart the modified form of the eruption. Mr. Dendy 
next examined the degree of affinity between variola and the disease which he 
calls variella, the nature of grease, and the various udder sores, and then pro- 
ceeded to examine the question as to the controlling influence of vaccinia over 
variola. Of this, he asserted, there could be no doubt; but he considered the 
statement made by Jenner and Aicken, that vaccination was a perfect preserv- 
ative from small-pox, was the foundation of the prejudices against it. It has 
been disproved by Mr. Estlin, who has seen a fatal case of small-pox, the 
sufferer having been vaccinated by Jenner himself. Mr. Marson also has said 
that several persons operated on by Jenner have been admitted since into the 
Small-pox Hospital. Nevertheless, the mortality from small-pox, amounting 
formerly, in the British Isles, to 40,000 annually — one-tenth of the total obitu- 
ary — has been so greatly abated in consequence of vaccination and the dimi- 
nution of variolous foci, that the author indulged a hope that the disease may 
be ultimately annihilated. Variella may, perhaps, occur in five cases out of 
one hundred, giving a prophylaxis of 95 per cent. ; the disease also, when it 
occurs, being much milder than inoculated small-pox without vaccination. The 
mortality of this modified disorder, as recorded by Thompson, was about three 
in 71; by Dr. Gregory's Report about six or seven per cent.; while of 
1300 unprotected persons 500 died of variola. Mr. Grove, of Wandsworth, 
states that, during the six months, from September to last March, there were 
126 cases of small-pox in that parish, of whom 66 had been vaccinated, 1 
had had small-pox, and 58 were unprotected. Of the 66 none died, and 
all had the disease mildly ; of those non-vaccinated 16 died, a large number 
had the distemper in its worst and most perilous form, and several will 
be disfigured for life. Mr, Waddington, of Margate, adds confirmatory 
evidence. Small-pox was epidemic in Margate twenty-five years ago; thirty- 
three children died, not one of whom had been vaccinated. Mr. Dendy next 
alluded to cases which were totally unsusceptible of the vaccine virus, which 
he contrasted with those which manifested extreme susceptibility. He re- 
marked that it is essential that the vaccine bud or germ have a congenial soil, 
uncontaminated by another poison, which, like a weed, might choke its healthy 
growth. Even during the prevalence of specific malaria, children — though the 
disease be not actually developed — are rendered especially insusceptible of 
vaccination. In asthenic, strumous, or cachectic systems, the vesicle will be 
blighted early, or it will burst out into excess or depravity of action, somewhat 
like the double or monster blossom. It becomes a disease more resembling 
grease or udder-sores, and its prophylaxis, of course, fails. Hence the advan- 



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239 



tage of a preparation of the system ; for it is in these depraved diatheses that 
variola so often becomes confluent, malignant, and bloody, or terminates fatally, 
even before the eruption would have appeared. The natural predisposition to 
infection is effected by a change in the crasis of the fluids. According to the 
acuteness or intensity of the agents that effect this in the system, will be also 
the degree or extent of elaboration from the system. In the mild form of 
vaccine, this depuration is effected by the mere efflorescence of an areolated 
vesicle, the visible sign of the constitutional influence, In the severer variola, 
the process of elimination is multiform — diarrhoea, hsematuria, cellular oedema 
and effusion, and induration and suppuration of glands, the more malignant 
form being attended by the bullae of pemphigus, terminating in ragged ulcers, 
or deep abscess under the crust. Modified variola or variella is not a mule, as 
it is reproductive, and may be communicated like perfect variola, both by 
malaria and by inoculation. It may also induce the specific fever, without 
eruption, in children and in nurses, who are protected in a, higher degree. Its 
inoculation for the fourth or fifth time, the author believed, would produce full 
variola, marked by true variolous symptoms, and he thought it might do so at 
once. In several isolated cases, in which some years ago he practised its ino- 
culation, there were both the secondary and tertiary fevers, the first a slight 
ery thism on the third or fourth day prior to the general eruption, and the other 
on the maturation of the pustule. When occurring casually, the first eruption 
of variella is on the hands, of variola usually on the face and breast. An 
argument against the identity of variola and vaccinia will be found in their 
running a parallel course, or in the one overcoming the other, variola being 
generally the victor when inoculated simultaneously. This draws attention to 
the question of incubation or latency of a germ. The poisonous atom will 
sometimes lie in the system for months and years. Rabies has occurred four- 
teen months after infection; syphilis may produce secondary or tertiary symp- 
toms years after the primary disease has subsided. The incubation of variolamay 
be, therefore, somewhat undefined ; nevertheless, from experiments, a fair con- 
clusion may be formed as to the usual period of this incubation, when vaccine 
prophylaxis may be induced; and from these the author judged that, if on the 
third day, before the onset of erethism, rigor, and headache, perfect lymph be 
inserted, prophylaxis is almost certain, assuming three or four days for the 
premonitory symptoms before the variolous point or papula appears. The 
vaccine vesicle will then be eight or nine days old, the areola will be becoming 
indurated, and erethism will exist. It is probable, Mr. Dendy said, that in this 
fever against fever, the essence of prophylaxis really exists. If under this 
influence the variolous papula proceeds, it will resemble umbilicated varicella 
or horn-pock. If the vaccine be used two days later, especially if there be 
bronchial or pulmonary symptoms present, it will be useless. The papula may 
be just apparent, but it will be blighted. There are, of course, exceptions to 
this rule. A woman was delivered, says Dr. Ilennen, while suffering from 
confluent variola ; the infant was vaccinated a few hours after birth. The 
mother died on the 11th day; the infant had true vaccine, and lived. Erup- 
tive disease is most virulent and perilous in warm climates, and secondary 
variola is not infrequent there. In the temperate countries, however, the 
author believes the occurrence of variola to be most rare after complete vacci- 
nation, especially as Dr. Bryce's mode has been adopted. His colleague, Mr. 
George, who has had most extensive experience, has seldom or never seen 
variella where five or six perfect vesicles have been produced ; and he thinks, 
therefore, that there is no proof of limitation of influence. Mr. Dendy believes 
that quality is better than quantity ; that one perfect vesicle is preferable to a 
crop of pale, undefined vesicles. If, therefore, there be two or three perfect 
vesicles, with annular and indurated areolae, combined with erethism of two or 
three days' duration, and followed by spotted or pitted cicatrices, corresponding 
with the cells of the vesicles, the impregnation and prophylaxis are as com- 
plete as from variola against the influence of malaria. Spurious variola, vari- 
cella, and variolous horn-pock may still occur by inoculation. The occurrence 
of variella from exposure to variolous malaria, in vaccinated children cannot 
be above four per cent. The inoculated small-pox has seldom been, Mr. Dendy 



240 



Progress of the Medical Sciences. 



[Jan. 



believes, followed by a secondary disorder. The case of Louis XVth is an 
exception. The cases of secondary variola are marked by extreme severity, 
especially in adults ; the fever will be acute or typhoid, and precede the erup- 
tion of variella. The cases of three children were given — one, the youngest, 
unvaccinated, caught small-pox and died ; the second child, well vaccinated 
two years previously, escaped altogether ; and the eldest, who was deeply pitted 
with small-pox, had a severe secondary attack, and also died. These children 
all slept in the same bed. The nurse, vaccinated in infancy, had a severe, 
but soon subsiding attack of variella. Other similar cases were adduced from 
other authors. From all this, we learn that prophylaxis is not a rule without 
exceptions, either on its direct or subsequent influence. With respect to the 
question of limitation of influence, by some it has been referred to an abstract 
law of time. Copland affirms that vaccination is more prophylactic than vario- 
lation for fourteen years ; and Dr. Gregory has referred to the extreme rarity 
of variella or modified variola, until fifteen years after vaccination was gene- 
rally adopted. Mr. Dendy believes that the first opinion may be extended 
throughout the life. He is of opinion that there is no law of limitation. That 
some occult change has been efiected either in the vascular, nervous, or gland- 
ular system is certain, whether we adopt the chemical, animal, or fungoid 
pathology. A sporule of a fungus may be sown or planted in the cutaneous 
tissue, as a vegetable seed in the earth, or rather as a bud is grafted beneath 
the bark. The cotyledon may thus be unfolded, and the developed germ is 
thrown up to the surface of the soil, terrestrial or cutaneous, and is there dis- 
played, either as a flower or as a pock, in all its characteristic forms and colours. 
If the germ be diseased, or if the soil be uncongenial or infertile, an imperfect 
efllorescence will ensue, a blighted or a bloated flower will be displayed. The 
soil may be naturally infertile, or it may be impoverished by over-stimulation, 
as in the area within the circle of the ring-worm, or of those vegetable eccen- 
tricities termed "the fairy ring;" both being the result of fungoid sporule 
spreading in a circle. To complete the analogy, the virus has poisoned the 
blood, and thrown out its flower on the surface. It has thus done its duty, 
and the system is thus both protected and depurated. The existence of the 
sporules was sought to be ascertained in crusts obtained from Mr. Marson, of 
the Small-pox Hospital. Mr. Dendy, in conjunction with Mr. Grove, of Wands- 
worth, dissolved them in liquor potassae, after which black points, which were 
considered to be the sporules, could be distinctly seen. The notion of a law 
of limitation is not conclusive. Some concurrent or casual causes may still be 
the explanation of secondary diseases. A want of balance between the anta- 
gonizing influences certainly exists ; a concentrated, intense, or virulent form 
of epidemic may overwhelm or saturate a system that would have resisted 
successfully a milder influence ; or a system reduced by disorder or any other 
depressing cause, would yield to an attack of disease which in a healthy state 
might have passed by unheeded. The proof of successful vaccination is not 
hypothetical ; it is displayed in the perfect vesicle and the constitutional excite- 
ment. If these requisites be fulfilled, the author believes we shall have little 
need to revaccinate, or to discuss further the vague question of limitation. — 
Med. Times, Oct. 25th, 1851. 

22. Analysis of One Huiidred and Forty-three Cases of Chronic Rheumatism, One 
Hundred of lohich were treated by the Nitrate of Potash and the remaining Forty- 
three by Colchicum. — Dr. John Cargill communicated to the New Castle and 
Gateshead Pathological Society (June 1851), an analysis of one hundred and 
forty-three cases of chronic rheumatism, one hundred of which were treated 
by the nitrate of potash and the rest by colchicum, Avith the facts he observed, 
and the inferences he thinks may be deduced from them, together with certain 
general principles which he conceives may be legitimately deduced both as to 
the treatment and pathology of rheumatism. 

The cases were nearly all in patients of a hospital, and were treated between 
the years 1847 and 1848. 

Of the forty-three cases treated by colchicum, fourteen only were cured, or 
about one-third, and the average duration of the treatment was fifteen and a 



1852.] 



Medical Pathology and Therapeutics. 



241 



half clays ; the average duration of the malady before admission being seventy- 
three days. In addition to the fourteen who recovered entirely, there were 
twelve relieved, whilst twelve remained no better. In one the complaint ap- 
peared to be worse, and in the remaining; four, circumstances arose which 
prevented any positive conclusions from being arrived at. 

Dose and combination of the Colchicum. — In rather more than half of those 
cured, that result was effected by the vinum seminum colchici in the dose of 
from fifteen to thirty drops thrice a day, with a little magnesia and sp. etheris 
nitrici. In a very few instances ten grains of Dover's powder were given a few 
times at bed-time. In six out of the forty-three, the colchicum was given in 
powder in four-grain doses thrice a day ; in one case it was given in six-grain 
doses thrice a day ; and in one case in two-grain doses thrice a day, all com- 
bined with pulvis cretas. In all but the last named it produced vomiting, 
griping, and diarrhoea in two or three days' time, and had to be left off for the 
Vinum with magnesia. Of this latter combination, the dose before mentioned 
viz., fT\^xv to XXX with fifteen grains of magnesia, and ^ss of sp. eth. nit. was 
the most effectual and the best borne. When the vinum was given by itself, it 
seemed slower in its curative effect, and when given in gjss doses or doses 
thrice a day, either alone or combined (a measure in a few instances adopted), 
it invariably had to be left off, from its producing very speedily its usual severe 
physiological effects, with great depression, and often cramps, the disease re- 
maining at the same time unaffected. I should add, that these results followed 
even when the above doses were attained to very gradually. 

Concomitant treatment. — In seventeen out of the forty-three cases, the warm 
bath thrice a week was used, and in fourteen out of this number manifest relief 
was obtained. In ten cases out of the forty-three, Dover's powder was given 
in from ten to fifteen grains each night, and in six of these cases it was followed 
by beneficial effects. Cupping was occasionally used, and generally with bene- 
fit. Bleeding from the arm was scarcely ever practised, and calomel, Epsom 
salts, blue pill or colocynth, were used as preliminaries, if constipation existed. 
As to the seat of the disease, it was in the several joints and muscles. In four 
cases wherein the rheumatism existed along with sciatica as its chief feature, 
the treatment by colchicum was fruitless. 

Of the one hundred cases treated by nitrate of potash in large doses, " there 
were sixty-one cured, being more than six-tenths of the whole, and the average 
duration of the treatment was thirteen and three-quarter days. In addition to 
the sixty-one cured, there were twenty who experienced great relief, but were 
not entirely cured at the time of dismissal ; there were five who experienced 
very slight benefit only, three received no benefit, and three got worse. In the 
remaining eight cases no positive conclusions could be arrived at. 

Dose and combination of the remedy. — The usual dose to begin with was 9ij 
thrice a day in barley water ; this was adhered to in many cases, throughout, 
but in a large number it was increased to ^j, ^iss, ^ij, thrice a day, and in 
one case ^iij every four hours was begun with, and continued without inter- 
mission for twelve days, without the smallest inconvenience to the patient, who 
was cured in that period. This was a bad case of two and a half years' pre- 
vious duration. The dose was often begun with, and continued at 3j, and with 
no disagreeable effect; sometimes 3j thrice daily, and sometimes 3j every four 
hours consecutively. 

Being desirous of ascertaining whether the duration of the malady might be 
shortened, or good in other ways obtained by combining the nitre with sp. 
nit. antim. tart, and tinct. opii, I adopted this in a considerable number of 
cases, and the result has shown me that no advantage is derivable from this 
practice. The dose of sp. of nitre was generally from tt^xv to ^ss or more; 
that of the vin. antim. ir^xv, and that of the tinct. opii lltv to each dose of 
the pot. nit. Sweating and diuresis were equally produced by the nitre alone 
as when given in the above combination. Of the three, the tr. opii alone 
appeared useful by frequently assuaging the severe pain. 

Disturbing effects. — It is of great importance to remark that this remedy was 
invariably administered in a large quantity of warm barley-water — not less 
than 3viij to each dose. When given in the above large doses, without a dilu- 



242 



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[Jan. 



ent and demulcent like barley water, it produces intense griping, with pallor of 
the countenance and cold perspiration, the pulse and heart's action flagging 
and coming down, and the greatest anxiety being experienced. This is fol- 
lowed by a dry red tongue, with enlarged papillae and much thirst. This I 
had an opportunity of seeing to an intense degree in one case wherein the 
nitrate of potash in those doses had been administered several times without 
any diluent by the oversight of a nurse ; she gave it in ^iss of plain water. I 
was on the point of applying numerous leeches to the epigastrium, fearing that 
gastritis was coming on, when the symptoms at last yielded to diluents and 
warm external applications, leaving no appreciable effects behind. 

I shall now mention what were the disturbing effects on the system observed to 
be produced by large doses of nitrate of potash in cases whei^e it had been duly 
taken with barley water, but had not been well borne by the system. Those 
effects were seldom manifested, the medicine, when properly diluted, seeming 
to act mildly and efficiently. When it is not tolerated, however, its effects are 
primarily on the nervous system. They are these : General debility of the 
limbs, especially the lower extremities, and the knees, too, particularly com- 
plained of. I have seen this carried to an extent which made the patients 
believe that they were seized with general paralysis ; the whole body seemed 
to be made of wood, and for some hours it was impossible for them to rise from 
their seat or to move hand or foot. To this were conjoined general tremblings, 
and the speech was affected ; occasionally the names of things were forgotten 
or mistaken ; there was also giddiness, and a painful rushing sound in the ears. 
I never in these rare instances saw any distortion of the features, and the symp- 
toms subsided in a few hours by diuretics or copious perspiration. In the 
event of such results occurring, the chief remedies I should recommend would 
be hot diluents and hot blankets. The subjects of them will be found generally 
of the purely nervous temperament, especially if associated with feeble power of 
the constitution. When the sanguine or bilious temperament is combined with 
the nervous, the remedy is better borne and may be pushed farther ; and it 
consists with my observation that the bilious lymphatic temperament, with its 
firm, harsh, muscular development, is the one in which this plan of treatment 
the oftenest succeeds and may be used the most fearlessly, as it is the one on 
which chronic rheumatism, when once established, displays itself with perhaps 
the greatest relentlessness. , 

The concomitant treatment was simple, and most generally dispensed with, 
altogether, (with a view to ascertain more accurately the value of the nitrate 
of potash itself,) except in cases of severe complication, in which the need 
for additional means, chiefly local, was urgent. It consisted in occasional 
warm baths and vapour baths. Cupping and leeching were had recourse to in 
such cases as showed a concentration of the disease in particular joints, as evi- 
denced by swelling, redness, and acute pain not shifting its seat. In dull 
chronic pains localized, occasional blisters were applied, and often with benefit ; 
and, towards the termination of the cases, a liniment of ammonia and turpen- 
tine was frequently useful in restoring the natural suppleness of the parts. 
When the pains were so great as to prevent sleep, and to harass the patient in 
an unusual manner, a draught of muriate of morphia, with solution of acetate 
of ammonia and water, was given at bed-time. The bowels were kept free by 
means of occasional light cathartics ; and the treatment was generally com- 
menced by giving a dose of calomel and colocynth, followed by a draught of 
infusion of senna and sulphate of magnesia. 

The diet enjoined was nutritious, being the ordinary diet of the house — viz. 
meat once a day, milk, rice, broth. In such cases as presented symptoms verg- 
ing on the acute, low diet was prescribed — such as milk, tea, sago, &c. In all 
old-standing chronic cases generous diet was found the best, accompanied even 
by ale, porter, wine, or gin. 

In the above one hundred cases the duration of the malady previous to admis- 
sion was widely different — so much so, that no analytic average could be struck 
with a view to results that would not have a tendency rather to conduce to error 
than to elucidate truth. I may state in general terms that the length of time 
in these cases previous to coming under the above treatment, was from seven 



1852.] 



Medical Pafliology and Therapeutics. 



243 



days to ten years, whilst there were a few who could remember no period of 
their lives in which they had not been victims, more or less, to the complaint. 

Two months, five years, six years, six months, one year Avere the most com- 
mon periods cited; and it should be remarked that nearly all the cases were of 
an unusually severe character, and had been under all manner of practitioners ; 
for many, despairing of a cure otherwise, had committed themselves to the ten- 
der mercies of unprincipled quacks, from whose fiery ordeal they had emerged 
with the conviction that now nothing but a residence in an infirmary with the 
reputation of our own could avail to benefit them ! 

Sex. — It is remarkable that, of the whole one hundred and forty-three patients, 
seventeen only were women, the remaining one hundred and twenty-six being 
men. The average age of the women was thirty-five and two-thirds, that of 
the men thirty-seven and one-third. From this it appears that, in this part of 
the country, men are about eight and a half times more liable to be affected 
with chronic rheumatism than women, or for one woman attacked with chronic 
rheumatism there will be between eight and nine men. This is in all proba- 
bility owing to the greater exposure of men to cold and wet; for I have found 
that in all of these cases the exciting cause, when any could be given, was in- 
variably cold and wet, or sudden transitions from a high temperature to the 
opposite. On referring to MS. notes of M. Louis' clinical lectures on this sub- 
ject, taken down by me at the time of their delivery at the Hospital of La Pitie 
in 1835, I find his experiments the same as to the exciting cause — invariably 
exposure to cold air or draughts (un ventfrais). 

The difference as to the frequency of rheumatism in France and England seems 
to be very great. Louis says that, out of one hundred cases of all sorts treated 
by him, he only found one of rheumatism ; and in the Paris Hospitals, during 
two years, it was rare that rheumatism, whether acute or chronic, ever fell 
under my observation. That the diJBFerence is great among us, will appear 
from the following fact : On analyzing a good while ago, a number of cases 
of all sorts, nearly all of them chronic, treated by me in this hospital, embrac- 
ing a period of five years, and amounting to nine hundred and fifty-nine, I 
found that eighty-six were cases of chronic rheumatism, being, on an average, 
one in eleven and one-sixth of the whole number. From this I think we may 
infer that climate exercises an immense influence in this disease ; and doubtless 
the same cause is, in regard to all other diseases, more powerful than we are 
generally aware of. How else can we explain the entire exemption of some 
countries from certain maladies ? In India and Egypt phthisis is unknown. 

I will take the opportunity of stating here, that I believe heart afi'ections to 
be very uncommon associates with chronic rheumatism ; nor do I think that 
this malady is apt to hefoUoived by cardiac disease. In the cases above an- 
alyzed it was constantly found that such of them as showed heart disease, had 
been preceded by rheumatic fever, and the heart affection could be traced to 
that period of acute disease. This is in conformity with the opinion now, I 
believe, generally entertained — viz., that acute rheumatism is very frequently 
accompanied by endocarditis, and, without very vigorous measures, is apt to 
be succeeded by permanent disorganization of the heart. I have seen this hold 
to the full extent admitted by Dr. Hope, though not perhaps to the degree main- 
tained by Bouillaud. In chronic rheumatism, properly so called, heart disease 
is, in my opinion, a rare occurrence. 

In speaking of acute rheumatism, I would record here my experience that, in 
patients under the age of jpuherty, acute rheumatism seldom or never happens 
without most seriously involving the heart; and the younger the patient (I 
have known it occur at five years) the more certainly fatal is this heart afi"ection. 
I have never seen a single subject in the above category who eventually shook 
off the heart affection and recovered. And, in addition to the ventricular 
hypertrophy and dilatation constantly present in these cases, as well as the 
valvular disease, I must mention a morbid appearance perhaps equally constant, 
and which I think has been overlooked by pathologists, or only casually if at 
all mentioned — viz., a tough, dense, false membrane lining the general interior 
of one or other of the dilated auricles, generally the left, obliterating the mus- 
culi pectinati almost entirely, and so converting the auricle into an uncontractile 
No. XLY.— Jan., Ib5"i. 17 



244 



Progress of the Medical Sciences. 



[Jan. 



sac ; thus furthering mitral regurgitation, and, by its undoubted effect of con- 
gesting the lungs and brain according to the auricle affected, mainly produc- 
ing the frightful dyspnoea and brain symptoms, which constitute the worst 
features of the malady. 

Of what value is the nitrate of potash in large doses in acute rheumatism ? I 
have had no experience of it myself in actde rheumatism, trusting as I have 
done to calomel, opium, Dover's powder, antimony, and, in the worst cases, 
bleeding : but my friend Dr. Fenwick, of*North Shields, who afforded me valua- 
ble assistance in preparing the first series of the above cases, when clinical 
clerk in this house some years ago, as did also Mr. Gibb, informs me that he 
has adopted it to a large extent in private practice in Shields, and has found it 
to answer in a remarkable manner. I would also refer you to Dr. Basham's 
cases of the acute form, and his treatment by the nitrate of potash in large 
doses — a paper read to the Royal Medical and Chirurgical Society of London, 
and published in the Medical Gazette, Nov. 24, 1848. His success was great, 
the urine acquiring a high specific gravity, and the salt being detected in it. 
The specific gravity was raised to 1030 and 1040, which he thinks was owing 
to the nitrate, though Dr. C. B. Williams attributes it to the urea and the 
lithates which are by its agency made to be present in the urine. Dr. Basham 
states his belief that, owing to its agency in acute rheumatism, there is a cer- 
tain degree of exemption from disease of the heart. 

I will conclude this paper (already too long) by recording certain facts and 
deductions which have manifested themselves to me from the careful investiga- 
tion I made of the above cases. 

In nine cases out of those wherein no relief, or only slight relief, was ob- 
tained, there were either purulent collections somewhere, or the usual common 
inflammations which precede suppuration — such as testitis, obstinate con- 
junctivitis, erysipelas. Are we entitled to deduce from this the general 
therapeutic principle, that in chronic rheumatism, Avhen it is in that aggra- 
vated form in which we have pus circulating in the blood, the treatment by 
nitrate of potash is not to be depended on, and must be relinquished for an- 
other ? 

Again, in eighty-one out of the one hundred, the cure was altogether effected 
in fourteen days by the nitrate of potash in large doses, and these were cases 
wherein, though severe, there was no suppuration nor ordinary inflammation of 
particular organs. It has been before laid down that nitrate of potash acts prima- 
rily on the nervous system. May we not infer, then, that those eighty-one cases 
were cases in which the nervous system was alone atfault? And, from the two 
considerations taken together, may we not look at rheumatism as a disease com- 
posed of two varieties — viz., that in which its assaults are expended on the nerv- 
ous system alone, and that other more severe one in Avhich pus circulates in 
the blood? Various observations and reflections have led me to take this view 
of the subject. Rheumatism is first a nervous and then a blood disease, and 
it maintains a distinct individuality in both these phases in a manner more 
singular than other complaints.* In what I call its nervous form it is a kind 
of llarlequin inflammation, and less mischievous than it seems. A little 
energy will knock it out of the system : if uncontrolled, it undergoes a trans- 
mutation, becomes grave, enters the blood, and changes it, and walks into the 
heart itself, the citadel of life. At present we want a set of careful microscopic 
experiments on the blood in all the varied conditions of rheumatism. Last 
year, at my request, Mr. Gibb took for microscopic examination small portions 
of the blood of several patients affected with different diseases. In the blood of 

* Look at its remarkable migratory character, its sudtJen metastases, its Hgbtning-like 
transitions from one membrane or muscle to others in remote parts! They present no 
analogy to any ordinary inflammation, but rather to certain phenomena seated at the 
extremities of the nervous system — urticaria, ambulant erysipelas, erythema, chorea. Dr. 
Hughes declares (Guy's Hospital Reports, vol. iv. 1846) that, next to fright, rheumatism 
is the most common cause of chorea (14 per cent.); and frequent occurrence of spas- 
modic affection with pericarditis, which is riieuntatic, has been particularly illustrated by 
Dr. Bright and Dr. Burrows. 



1852.] 



Medical Pathology and Therapeutics. 



245 



one who had no trace of inflammatory affection of any kind we found, to our 
surprise, numbers of pus globules. In a few days there was developed in this 
patient a severe erysipelas, which finished by becoming phlegmonous. Here, 
then, inflammatory disease existed in the blood for a certain time without be- 
traying its presence, untilat length its increase became such [vires acquirit eiindo) 
that nothing but an acute attack upon the skin sufficed for its elimination. 

3. In cases wherein mercury has been previously extensively taken, and in 
cases where there is syphilitic malady present in the system, whether mercury 
has been taken or not, the nitrate of potash is without power. The remedy is 
hydriodate of potash. 

4. In cases of general chronic rheumatism, in which sciatica is the most 
painful feature, the nitrate of potash will banish the complaint from the other 
parts, but will not avail against the sciatica. In this event, arsenic, where it 
is borne, is the most powerful remedy. 

5. In cases wherein the symptoms are doubtful, being circumscribed though 
severe, and simulating sucii other common inflammations as pleuritis, peri- 
tonitis, ordinary cerebral or spinal meningitis, and even spinal irritation and 
hysteria, the state of the tongue, if it appear as if overlaid with a coat of deep or 
light white paint, so constant in the rheumatic condition, will most essentially 
guide the diagnosis. — Loud. Med. Gaz., October, 1851. 

23. Statistical Report upon Cases of Disease of tlie Heart, occurring in Si. 
George's Hospital, especially in relation to Rheumatism and Albuminuria. — A very 
valuable paper on this subject was read before the Royal Medical and Chirurgi- 
cal Societ}-, by Dr. Barclay. The author first mentioned eight cases of acute 
rheumatism fatal during the rheumatic attack, among which he particularly 
called attention to a case of severe pericarditis, in which no friction-sound was 
ever heard : and to a case in which no inflammation existed either in the heart 
or pericardium, in which a systolic murmur was distinctly heard. He next re- 
ferred to sixteen cases of recent pericarditis, and four in which it was not quite 
recent, occurring independent of acute rheumatism ; two of which were traced 
to recent peritonitis, and one to recent pleurisy; a large proportion of the re- 
mainder were associated with albuminuria, but it seemed to him that, in many 
of these instances, tumultuous action of the heart during life had very much 
to do with the traces of pericarditis found after death. He detailed one case in 
which this action of the heart seemed to be its only cause. Eleven cases were 
then mentioned in which recent lymph was found on the valves, and two in 
which it was not quite recent. Two were traced to malformation, and two to 
disease of the kidney ; seven were accompanied by old disease. In six of these 
the old disease was probably due to by-gone attacks of rheumatism, and he re- 
marked it as a curious fact, that this condition was so much more frequently 
than any other associated with recent inflammatory action. Twenty-six cases 
of old pericarditis were then considered, including six of adherent pericardium, 
and three in which the adhesions were nearly universal ; besides a great many 
not mentioned, in which white spots were fonnd. He believed these cases in- 
dicated that universal adhesion is not the common result of rheumatic pericar- 
ditis ; and, considering the age of the patient at death, and the condition of the 
heart, that it is not the most favourable termination of the attack. More than 
half the cases which had at some period or other suffered from acute rheuma- 
tism indicated old pericarditis. Twenty cases of old valvular lesion were pro- 
bably caused by acute rheumatism ; twenty-six occurred in persons who had 
never suffered from rheumatism at all; sixteen were regarded as doubtful cases. 
Among the rheumatic cases there is a great preponderance of simultaneous 
lesion of the aortic and mitral valves ; next of the mitral alone, and scarcely any 
of the aortic alone. It seemed probable, in most of these cases, that during 
the first attack of rheumatism the mitral valves alone were inflamed, and at 
some future period also the aortic secondarily. Valvular lesion was found 
associated in twenty-two instances with diseased kidney, and albuminous urine; 
in twenty-six instances the kidneys were healthy, and in thirteen instances the evi- 
dences of disease were more or less obscure. The tricuspid valves were also 
afifected in ten cases, and the pulmonic valves once. It was stated that among 



246 



Progress of the Medical Sciences. 



[Jan. 



these cases disease of the aortic yalves was most frequently found associated 
with hypertrophy, and in aortic regurgitation also with dilatation ; disease of 
the mitral valves mostly with dilatation ; adhesions of the pericardium more 
generally with dilatation ; atheroma of the aorta and disease of the kidney 
were found accompanying a large majority of the cases of simple hypertrophy. 
In 141 cases of diseased kidney, taken indiscriminately, hypertrophy occurred 
fifty-five times, and dilatation thirty-six times together or separately in sixty- 
three individuals, and in seventy-eight the heart was healthy. The author then 
detailed his observations in regard to rheumatism, made upon cases in the hos- 
pital, which did not prove fatal. He found the heart diseased in forty-four per 
cent, of acute cases, in eleven per cent, of subacute, and four per cent, of chronic 
cases; in all the chronic cases, and many of the subacute, the individual had 
experienced a more severe attack of rheumatism at some former period ; some 
of the acute cases were also examples of a second or subsequent attack. Taking 
those cases only which were admitted with a first attack of acute rheumatism, 
he found cardiac inflammation occur more frequently in females than in males, 
and in the largest proportion between ten and fifteen years of age, after which 
it gradually declined to forty. The majority of the acute cases are found under 
twenty-five years of age, and after that there is a much larger proportion of 
subacute cases. There Avas a larger proportion of males than females admitted 
with confirmed disease of the heart; but the difi'erence is less striking if those 
of rheumatic origin alone be considered. At the earlier ages almost all cases 
of confirmed disease of the heart owed their origin to acute rheumatism, while 
at more advanced ages it almost ceased to be found among the causes. — The 
paper was accompanied by a table, exhibiting the principal lesions found, on 
post-mortem examination, in the cases on which the report was based. — Medical 
Times and Lancet, Nov. 22, 1852. 

24. Spircea TJlmaria, or Meadoiu- Sweet, in Dropsy. — M. Tessier, of Lyons, has 
made some experiments on the Spirasa ulmaria in certain cases of dropsy, the 
results of which he has published in the Bulletin de Therapeutiqve. 

A person in the prison at Perrache had ascites, connected with intestinal 
irritation. After all other known diuretics had been tried in vain, M. Tessier 
prescribed a quart of the decoction of spirgea daily. From the third day, the 
patient passed much more urine than before. At the end of sixteen days, the 
medicine was suspended, and the urine immediately became scanty. It was 
resumed, and continued for six weeks ; and the ascitic efi'usion was absorbed 
without the production of any debility. In a case of hydarthrosis of the knees, 
the decoction of spiraea seemed to aid materially the action of vesicants, by in- 
creasing the renal excretion. In a young woman affected with the heart-disease, 
it produced abundant diuresis, without lowering the circulation like digitalis. 
A young man accidentally took some of the decoction, in mistake for a pectoral 
ptisan. Four days after, he spontaneously remarked, that he had passed an 
enormous quantity of urine for forty-eight hours after. His condition became 
improved. 

M. Tessier believes that meadow-sweet possesses diuretic properties ; that it 
is also slightly astringent and tonic ; that it is agreeable to the taste, and pro- 
duces no disturbance of the stomach or of the nervous system. All parts of 
the plant seem to be endowed with the same properties : the flowers are perhaps 
less active. The spira3a grows in March and April, and flowers in May and 
June. — Land. Journ. Med., Oct. 1851. 



1852.] 



Surgery. 



247 



SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE 

SURGERY. 

25 . Si/mptoms, Paihology, Diagnosis, and Prognosis of Enlarged Vaginal Bursce. 
— Mr. Wm. Coulson gives the following interesting account of the pathology, &c. 
of enlarged vaginal bursoe. " In using the terms superficial and deep,^' he 
says, *'I allude, of course, to the primary connections of these structures, and 
in no way to the situations which they may subsequently acquire. A collection 
of fluid, either in the large theca of the flexor tendons of the forearm, or in a 
sac connected with this membrane, may make its way towards the surface so as 
to elevate the skin like the pointing of an abscess, and to render it thin and dis- 
coloured ; and yet we must include this under the head of deep bursas. The 
same remark may be applied to the bursas in the neighbourhood of the knee-joint, 
connected with the tendon of the semimembranosus muscle, which frequently 
becomes enlarged and projects into the popliteal space. 

The clear albuminous fluid, secreted in the healthy state by these structures, 
undergoes various modifications by inflammatory action. At first it becomes 
thinner and more sparing than natural, and the part, when examined, com- 
municates to the fingers a crackling sensation. Then it may be more abundant, 
and cause distension of the sac, attended by severe pain. If this alGPection be 
deeply seated, and beyond the reach of surgery, it gives rise to very consider- 
able suffering, and excites symptoms which are not readily understood. If, for 
example, it occur in the bursee of the tendon of the psoas and iliacus muscles, 
it may be readily mistaken for incipient disease of the hip-joint. In course of 
time, the fluid of an inflamed bursal sac entirely loses its oily nature, becomes 
serous and watery, and is frequently of a yellow, or even reddish-brown hue, 
from admixture of blood. 

But there are sometimes found, especially in the synovial theca of the flexor 
tendons of the wrist, numerous hard fibro-cartilaginous bodies, like millet seeds, 
floating loose in the distended sac. They have been improperly called hydatids, 
but are, in truth, growths from the vascular fringe of the membrane, project- 
ing inwards towards the cavity, and covered by epithelium. As they increase 
in size, the pedicle connecting them with the membrane is eventually broken 
by the friction of the parts contained within. We have instances of similar 
bodies becoming loose in the cavity of a synovial sac, in certain rheumatic affec- 
tions of joints. The enlarged bursa is not uncommonly loculated, or divided 
into partitions by septa or bands. In general, however, the compartments 
readily communicate one with another. 

The most frequent seat of enlargement is the synovial sheath, which invests 
the flexor muscles of the fingers, and extends from the forearm under the annu- 
lar ligament to the palm of the hand. When distended by fluid, it produces a 
considerable elevation, which is often constricted and divided into two parts by 
the annular ligament of the wrist. The walls, when laid open, are found to 
be thicker than natural ; the lining membrane is rough ; the fluid contained 
within is opaque, yellow, or yellowish-brown, and thick, and it frequently con- 
tains those small bodies above-mentioned, which are smooth externally, and 
often hollow ; some, however, are solid, of fibro-cartilaginous structure, and 
resemble grains of rice in general appearance. The cyst, when minutely ex- 
amined, is generally found thickened and of a fibrous structure ; externally it 
is connected to the parts around by loose areolar tissue. Internally it presents 
a velvety or roughened appearance, and there proceed from it numerous fringes, 
of which some are pedunculated. Embedded in these fringes are sometimes 
those hard white bodies, which are frequently found free in the sac ; some of 
them are elongated and seed-shaped, others flattened and triangular, or round. 
The smaller are generally solid ; the larger contain a cavity. These bodies 
were described by Dupuytren as hydatids ; and the term " hydatiform'^ has 
been applied to the bursal swellings about the wrist, under the idea that such 
parasites were the cause of the enlargement of the sac, and of the collection of 
fluid. Deviations, both in the quantity and in the consistence of the synovial 



248 



Progress of the Medical Sciences. 



[Jan. 



secretion, may produce a peculiar condition of these fibro-serous canals, which 
yield upon pressure a crepitating or crackling sensation. This sound may be 
heard in whatever region of the body fibro-serous grooves naturally exist. It 
is commonly heard in the region of the shoulder-joint, where it is connected 
with a morbid condition of the sheath of the long tendon of the biceps flexor 
cubiti. M. Poultain relates a case, in which these symptoms gave rise to the 
notion of fracture ; and in the Lancet for 1836, 1837, the late Mr. Wallace of 
Dublin mentions a case, where an affection of this kind, in the extensor tendons 
of the thumb of a young woman, had been mistaken for fracture. The same 
sound has been heard about the tendons of the hamstring, and behind the in- 
ternal malleolus in the sheaths of the flexor muscles of the foot ; behind the 
external malleolus, along the course of the tendons of the peronei muscles and 
those upon the instep, and in other parts. 

Although violence is often assigned as the cause of this affection, its origin, 
in the greater number of cases, is obscure. It is more likely to depend upon 
the influence of some constantly acting source of irritation than on any sudden 
injury, and the symptoms which usher it in support this view. At times, indeed, 
there is at the commencement acute pain, which, however, gradually subsides 
when the part is at rest, and is excited only upon movement. But more com- 
monly there is little or no pain felt by the patient, until he makes a greater effort 
than usual, when the attention is for the first time directed to the part. Upon 
awaking in the morning, the part is stiff, but the stiffness goes off after a little 
exercise. There is rarely either heat or redness ; the latter is generally second- 
ary, and referable to accidental rubbing and friction. There is always some 
amount of swelling, the form of which depends upon the natural connections of 
the part affected. If the disease occur in the sheath of the extensores ossis 
metacarpi and primi internodii pollicis, the tumour extends obliquely across the 
lower part of the forearm, from the ulnar to the radial side. If it affects the 
radial extensors, the swelling, wider below than above, passes over the inferior 
and outer part of the broad extremity of the radius. Any anatomist can tell 
in what groove this affection is situated, by making the patient move under his 
direction the different muscles of the forearm. In severe cases, the stiffness ot 
the limb, the sensation of weakness, and the pain upon movement, are so con- 
siderable, that a man is unable to follow his employment ; and, in the higher 
ranks of society, accomplishments, such as instrumental music, which require 
great freedom of movement, have to be suspended, or, indeed, entirely given up. 

The manner in which these tumours show themselves is as obscure as their 
etiology. Sometimes a peculiar creeping sensation is experienced down the 
fingers, wrist, and forearm ; at other times there is stiffness, weakness, and diffi- 
culty of movement. In other cases, it is the tumour which first attracts the 
patient's attention ; and the symptoms above related are felt only at intervals, 
and after any greater exertion than usual. The shape of the swelling, as it 
affects the large bursa mucosa surrounding the flexor tendons of the fingers, is 
variable ; sometimes it commences in the palm of the hand, at other times 
in the lower part of the forearm ; and in both instances it soon becomes bound 
down by the annular ligament. Indolent, and painless upon pressure ; fluctu- 
ating, and presenting irregular projections, it appears as a bilobed mass, upon 
which the fingers have an involuntary tendency to close. If the contents be 
steadily and forcibly squeezed dowuAvards towards the hand, a movement may 
be communicated to the fingers, along whose thecae the fluid is pushed. And 
during this examination, when the fluid is pressed backwards and forwards 
from one end to the other of the enlarged sac, a ^ecwWiiY frottement is felt, upon 
which Dupuytren laid great stress as a diagnostic symptom. 

The pain and sensation of weakness produced by such a tumour are so great, 
that the limb soon becomes useless ; the fingers are permanently bent, and the 
attempt to extend them excites a dragging sensation along the entire cyst. 

Cases occur, when the tumour is large, in which the ulnar artery and any 
superficial palmar arch are raised upon the SAvelling ; the radial artery, too, may 
be separated from the bone, before it turns under the styloid process of the 
radius. The integument of the palm of the hand becomes thin from want of use, 
loses its transverse markings and lines ; it is elevated into a soft, smooth, com- 



1852.] 



Surgery. 



249 



presaible swelling, extending, in severer cases, along the flexor surface of the 
fingers. Continued position of the fingers in this abnormal state, leads to 
permanent changes in their articulating surfaces, and in the ligaments which 
unite the bones one to another ; hence it arises that in old cases, where the 
flexion has existed for a considerable time, the evacuation of the cyst, or the 
cure of the bursal enlargement, does not restore the mobility of the fingers. 

Diagnosis of these tumours is not at all times so easy as many surgeons have 
affirmed. If situated on the palmar surface of the wrist, the bursa is recognized 
as a fluctuating bilobed mass, the shape depending upon the size of the sac, 
and the constriction of the annular ligament. But the contents may be of such 
consistence, that there will be no fluctuation. But the crepitation to which I 
have before alluded, produced by the passage of the fluid containing the hard 
grain-like bodies from one compartment to another of a sac, through a narrow 
orifice, may be taken as characteristic of the nature of the tumour, in connection 
with the constriction produced by the annular ligament. 

M. R-obert, however, has recorded the following case of fatty tumour of the 
hand, resembling, in many of its physical signs, the affection which we are now 
describing. [Annales de Thempeutique, tome ii.] 

A j'oung man, aged 27, a butcher, was admitted into the hospital, with a 
tumour of the size of half an orange, situated upon the ulnar side of the palm 
of the right hand. It was subcutaneous, soft, and elastic, giving a peculiar 
crackling sensation upon pressure, and lying in front of the flexor tendons; it 
was trilobed, and deeply grooved. The fingers were slightly flexed upon it. 
The patient had noticed it first when about twelve years of age. It remained 
stationary till three years ago, when it suddenly increased in size. After an 
explanatory puncture, a crucial incision was made, and the skin was reflected 
back, when a tumour was exposed, composed of two portions set one within the 
other ; the inferior flat, but deeply hollowed in the middle ; the other portion of 
a cylindrical form, lodged in the hollow of the preceding. The second portion 
was movable upon the first; and the friction thus produced, communicated to 
the hand the "crepitating sensation'' above referred to. 

An important point of diagnosis, rendered more valuable by accurate modern 
research, is derived from the consideration of the natural connections of the 
bursal sac afi"ected by disease. The origin of the tumour, its inclination rather 
towards the ulnar than the radial side, the efi'ect produced upon the fingers, the 
free movements of the thumb — these are points which indicate that the disease 
originates in the bursa of the general flexor tendons. The circumscribed swell- 
ing of the radial side of the hand, the weak condition of the thumb, the inability 
on the part of the patient to bring it into firm apposition with the rest of the 
hand, pronounce the bursal afiections to be limited to the tendon of the flexor 
longus pollicis. 

Prognosis. — Many years may elapse before these tumours acquire any great 
magnitude. Slow in their growth ; often painless ; obscure in their origin ; 
they pass unheeded, especially among those whose occupations require neither 
the exercise of great strength, nor the application of great delicacy of touch. 
Ultimately, after years of enlargement, they become stationary, but they do not 
disappear ; at least, there is no satisfactory case of the kind upon record. All, 
then, that we can expect nature to efi'ect, after the establishment of the disease, 
is the arrest of the further enlargement of the tumour. 

As regards the serious nature of these afi'ections, those tumours confined to 
a single finger, often limited in extent, are less to be feared than those in the 
palm of the hand, involving the entire bursa, and requiring the performance of 
an operation, which, though simple as regards execution, may be followed by 
dangerous symptoms. — Lond. Journ. Med., Oct. 1851. 

26. Treatment of Enlarged Beep-seated Bursce. — Mr. Wm. CouLsoisr, in a valu- 
able paper in the Bondon Journal of Medicine, (Oct. 1851,) makes the following 
remarks on the treatment of enlarged deep-seated bursse. It is customary, in 
the chronic cases, to employ counter-irritants, such as blisters, irritating oint- 
ments, etc. The emplastrum ammoniaci cum hydrargyro, spread upon leather, 
may be applied to the limb, and secured by a firm bandage ; the whole to be 



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•vrorn for several weeks. If the fingers are stiff, friction of the limb and passive 
motion may be resorted to, when the swelling has in great measure disappeared, 
and the fluid is nearly absorbed. The arm may be soaked and rubbed in a 
warm arm-bath daily. When the limb is immersed in a heated fluid, much 
greater force may be used with impunity, than under the ordinary circum- 
stances. 

The operations which have been recommended for the cure of those synovial 
tumours are the following : Extirpation ; incision, either simple or combined 
with irritation of the surface of the cyst ; subcutaneous puncture ; and iodine 
injections. 

As regards extirpation, it is extremely difficult, on account of the extent of 
the connections of the sac. 

I have generally contented myself with making an incision longitudinally 
through the most prominent part of the swelling, and evacuating the contents. 
Some amount of inflammation usually supervenes ; and the cavity becomes ob- 
literated in the usual manner. But there is a risk of the inflammation proving 
very severe, and extending along the muscles of the forearm, attended with a 
high degree of fever and constitutional disturbance. Death has ensued from 
such an attack ; and in other cases, in which the inflammation has been subdued 
by active treatment, the mobility of the fingers has been permanently impaired. 

The use of the seton may lead, he remarks, to results difficult of management, 
and even dangerous, and he quotes a case recorded in the Legons Orales of Du- 
puytren, in which a fatal result followed its employment. 

This case made a great impression upon Dupuytren, who for the future 
changed hig mode of operation. In place of a simple opening in the most 
prominent part of the tumour, he made large incisions ; and substituted for the 
seton a piece of lint interposed between the edges of the wound, to prevent their 
union. Mr. Syme of Edinburgh, impressed with the same fear of constriction 
in these cases, has recommended the preliminary division of the annular liga- 
ment, as was suggested a long time ago by Warner. Mr. Syme has published 
a successful case in the Edinburgh Monthly Jouriial for October 1844. 

Professor Gerdy has successfully practised the subcutaneous incision ; and 
such an operation has much to recommend it, as there is not that fear of the 
severe inflammation which often attends the exposure of the cyst. The opera- 
tion should be combined with pressure ; still, though less dangerous, it is also 
less sure than incision, and there are many cases in which it is impracticable. 

Iodine injections have been recommended by Velpeau in the treatment of 
these bursal enlargements, but many objections have been raised against the 
practice, on account of the chance of severe inflammatory disturbance. I am 
inclined, however, to recommend this plan for adoption. 

M. Chassaignac has related a case in the Gazette des Ropitaux, in which, after 
having evacuated the fluid, he injected through a canula, first some warm water 
to clean out the cyst, and next some tincture of iodine. The cyst was then 
emptied, moderate pressure upon the walls was exerted by means of a com- 
press, and the opening made by the trocar was properly secured. Some in- 
flammation supervened; but it yielded to treatment, and the case terminated 
favourably. 

An analysis of the cases in which this treatment has been tried is decidedly 
favourable to the practice, although I am not quite prepared to agree with 
Michon, that there is less chance of inflammation than of relapse and the re- 
collection of the fluid. An attack of inflammation of the hand is always a 
serious matter, often so impairing its movements, as no subsequent endeavours 
on the part either of the patient or of the surgeon may be able to rectify. 

Professor Bouley has demonstrated the superiority of iodine injections over 
other means of exciting inflammation, and he has succeeded thus in dispersing 
tumours of large size, without danger or inconvenience. If therefore simple 
puncture or incision should fail in the first instance, I recommend this practice 
as far preferable to the introduction of setons and other foreign bodies. 

It must not be supposed that the surgeon has effected all his task by the 
evacuation of the fluid and the obliteration of the cyst. There remains for him 
to restore the mobility of the fingers, long since become stiff, semi-flexed, and 



1852.] 



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261 



in great part useless. For this purpose he must recommend exercise, passive 
motion, baths, etc., and by perseverance the hand may again be brought into a 
useful state. 

It is singuhir that this aiFection of the bursa of the flexor muscles of the 
forearm and hand should be rare in the corresponding structure in the lower 
extremity, more especially considering how the foot is compressed in tight boots, 
and exposed to constant violence and injury. A case, however, of the kind is 
related in the Medical Times, July 13, 1850. A young lady, aged 20, of slight 
frame, but in the enjoyment of very good health, consulted Mr. Stanley for a 
painful swelling of the right foot and ankle. Five years previously, she had 
been greatly fatigued by a walk of extreme length, and she arrived home much 
exhausted, but was sufficiently recovered in a few da3'-s to go about as usual. 
From that time, however, the right foot and ankle were weak and painful, and 
swelled upon her taking the least exertion. About two years ago the swelling 
became permanent, and the ankle, which was easy when at rest, was so painful 
when she attempted to walk, that she was obliged permanently to keep the 
horizontal posture. Every variety of treatment had been adopted without avail ; 
the swelling about the joint increased until the integuments gave way, and there 
formed an ulcer, whence flowed a thin sero-purulent fluid. There was a large 
swelling between the tendo Achlllis and the os calcis, extending down to the 
sole of the foot ; part of the swelling was firm, part was elastic, as if contain- 
ing fluid ; the integuments covering it were thinned and livid, and had given 
way in one spot, exposing a fungous-looking mass of granulations ; the move- 
ment in the joint was perfect. The limb was removed, and the morbid change 
was found to be limited to the synovial thecae which surround and accompany 
the tendons of the tibialis posticus and the flexor communis digitorum muscles 
of the sole of the foot. It was therefore strictl}^ circumscribed and surrounded 
by healthy structures. The thecas were thickened ; their usual bright synovial 
surface was converted into a dull, uneven, velvety structure, from which was 
produced a soft growth composed of cytoblasts, and a small quantity of deli- 
cate fibrous tissue. This growth made its way upwards between the posterior 
surface of the tibia and the tendo Achillis, and downwards into the sole of the 
foot, between the flexor brevis digitorum and the flexor accessorius muscles, 
both of which were quite healthy. The flexor tendons were unaltered in struc- 
ture, but were surrounded by the soft growths above described, and by a large 
quantity of morbid synovial secretion, which seemed to be contained in more 
cavities than one ; for behind the malleoli it was of pale straw colour, and 
somewhat stringy, whilst in the sole of the foot it was of watery consistence, of 
red colour from the admixture of blood, and contained coagula. 

27. Treatment of White Swelling loith Fungosities of the Synovial Membrane. — 
M. Laugier criticises the various means which have been proposed for the 
treatment of white swelling with fungosities of the synovial membrane, and ob- 
serves, that none of them have 2i direct action — none act on the vessels themselves 
which constitute the morbid development from the membrane. The researches 
of M. Richet on these fungosities have shown their eminently vascular nature. 
It is also well known, that the external surface of the synovial membrane is 
furnished with a richly vascular areolar tissue, which soon participates in the 
disease by becoming extraordinarily developed, from the organization of the 
coagulable lymph which it secretes. Hence the synovial membrane acquires a 
great thickness, from the fungosities and false membranes interiorly, and the 
thickening of the areolar tissue externally. 

From observing the vascular relation established between the fungosities and 
the external areolar tissue, M. Laugier has derived a new method of treatment. 
He believes it to be perfectly harmless, to rapidly produce alleviation of the 
pain, and to diminish immediately and permanently the fungous areolar tissue 
external to the synovial membrane. 

The treatment proposed consists in boldly plunging a lancet to the depth of 
several lines into the white swelling, at points where the fungous areolar tissue 
is thickest. Several punctures maybe made at the same time. The immediate 
effect is an abundant local hemorrhage from each puncture : from sixty to seven- 



252 



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[Jan. 



ty grammes of dark venous blood escape. The fungosity diminishes ; it does 
not disappear completely, but, in place of being elastic and resistant, it becomes 
supple. This diminution continues for some weeks. The punctures should be 
repeated, either in the same or in different spots, to obtain a complete and per- 
manent cure. Local bleeding from the vessels of a morbid tissue may well be 
understood to have great efficacy. Lond. Journ. Med., Oct. 1851, from Union 
Medicale, July 31, 1851. 

28. On Galvano-puncture in the Cure of Varicose Veins, and of Aneurisms. 
By Professor Schuh. — The experiments performed by the author have given 
the following results, which, on account of their interest, we shall detail at 
length : 1. The coagulation of the blood is not always the immediate conse- 
quence of electro-puncture employed during from ten to twenty minutes ; on 
the contrary, it is frequently not observable until after the lapse of many hours, 
or until the second day, and it increases in degree during one or two days ; it 
is, therefore, manifestly due to inflammation excited by the operation. Where 
the coagulation takes place during the operation, it is certainly to be attributed 
to the chemical, and also partly to the mechanical influence created by the 
presence of the foreign body. The more the mass of blood is kept at rest, the 
greater is the probability that coagulation will set in during the operation ; it 
is, therefore, advisable to apply a bandage above and below the seat of opera- 
tion. The hardness shows itself most frequently earlier at the positive than at 
the negative pole ; if the needles are, for example, three or four inches apart, 
the entire intervening space does not become hardened at the same time, but 
the central point between the two insertions remains more or less soft. 2. 
Sensibility to the galvano-puncture varies in different individuals ; on closing 
the contact, all experience pain, which, however, in one patient quickly ceases, 
or passes into a gentle prickling sensation ; while, in another, it continues very 
violent, and even occasions spasms of the limbs. The pain occasionally abates 
to return again in the same degree. It was most frequently more acute at the 
positive pole. 3. During the galvanic action, a grayish-white, lenticular, semi- 
transparent vesicle very soon forms around the needle of the zinc pole ; a 
slightly bluish one subsequently appears at the negative pole ; both are sur- 
rounded by a narrow red halo, in which the elimination of gas can be seen, and 
even crepitation can be perceived. 4. On the following day, a brown stain is 
observed on the burnt cuticle in the situation of the vesicle, or more frequently 
a little scab, which falls off, without suppuration, in the course of two or three 
weeks, leaving a slight depression. On one occasion only did the formation of 
an eschar penetrate deeper. 5. The subsequent inflammation is indicated by 
the occurrence of pain. On the second day, the hardness, heat, and sensibility 
have increased ; the latter, however, is seldom very excessive. These pheno- 
mena continue for a few days only ; the coagulum of blood in contact with the 
inner coat diminishes, and draws the walls towards the centre, causing a 
diminution of the calibre of the vein. 6. A single application will scarcely 
ever effect a cure ; the electro-puncture must be frequently repeated. 7. Its 
employment is not free from danger ; phlebitis, with secondary pyaemia, is no 
uncommon consequence of the operation. Moreover, it is evident that prudence 
in the choice of cases is indispensable, and that its performance is not admis- 
sible except when the trunks of the superficial veins of the lower extremity are 
alone dilated. In aneurisms, in which the application of ligature to the vessel 
itself is no longer possible, or would be attended with too great danger, electro- 
puncture appears to offer a chance of success only when preceded by the ap- 
plication of bandages to the periphery of the limb. — Dublin Quarterly Jour. 
Med., Nov. 1851, from Vierteljahrschrift fur die praldische Heillcunde, Prag. 1851, 

29. Rupture of the Bladder from external pressure. — Recovery. — Dr. Tomkins 
of Yeovil, records in the Provincial Medical and Surgical .Journ. (Oct. 29th, 1851) 
a case of rupture of the bladder which is very interesting as showing that this 
accident is not necessarily fatal. 

The subject of it was a man who, whilst undermining some earth in a deep 



1852.] 



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253 



cutting for a railroad, was thrown from a height of more than twenty feet; the 
ladder on which he was standing was knocked from under him by the sudden 
fall of an almost solid portion of earth, weighing several tons. The man fell on 
his back, and the pickaxe with which he was Avorking, together with the ladder, 
were thrown several feet behind him. The main bulk of earth descended on 
his abdomen, and it required the united efforts of nine or ten men to lift it from 
his body. 

The surgeon who first saw him, found the abdominal integuments much con- 
tused, and an extensive lacerated wound in the perineum, through which three 
fingers could be passed with ease, and which enabled him at once to discover 
that the bladder was ruptured. 

When seen by Dr. Tomkins, the patient was pulseless. There was considera- 
ble hemorrhage from the wound, which was three or four inches in extent, lay- 
ing open the posterior portion of the urethra. Dr. T. passed his finger through 
the wound, and found the bladder extensively ruptured, and at the same time 
introduced a catheter by the urethra, and brought it readily through the rent 
in the perineum. When reaction took place, the patient suffered most intolera- 
ble pain, accompanied with sickness and vomiting, for which a grain of opium 
was given every hour or two, with the best effect. 

It is unnecessary to detail the symptoms and treatment of the case from day 
to day. Considerable sloughing of the integument of the abdomen took place. 
Fomentations and poultices were applied; the bowels were kept open by the aid 
of injections and castor oil ; his strength was kept up ; and opium given freely 
to soothe his pain, to the extent of from eight to sixteen grains a day. The 
wound soon began to assume a healthy aspect. A catheter was passed from 
day to day, and occasionally kept in the bladder a few hours at a time. At the 
expiration of two months the wound had healed, leaving the course of the urethra 
rather tortuous ; but at the end of another month, when the man left the town, 
the bladder was so far restored as to enable him to retain from eight to twelve 
ounces of urine. 

With regard to the question how this wound was produced, Dr. T. observes. 
It is certain it was not from the entrance of any extraneous substance from 
without, for the man had on a pair of new corduroy trousers, suspended by his 
braces, and there was not the slightest rent about them. It is, therefore, evident 
that the weight and pressure of the earth compressed the bladder so completely 
within the pelvis that the urine was sent forward with such force as to tear the 
urethra and perineum in the manner described ; and this tends to point out to 
us the utter impossibility of deciding, in many cases, the precise mode in which 
wounds are inflicted, or the weapons or missiles by which they have been caused." 

30. Fracture of the Os Hyoides. By Dr. Grunder. — The following case 
proves that this affection is not always so easy of recognition as it is usually 
considered to be. A labourer, set. sixty-three, fell from a wagon on his face, 
and discharged a large quantity of blood by the mouth. He found he could 
not swallow, and when seen twelve hours afterwards complained of severe pain 
in the neck and nape, with inability to turn his head, though no injury of the 
vertebras could be detected. His voice was hoarse and difl&cult. On attempting 
to drink, the fluid was rejected with violent coughing, the patient declaring he 
felt it as if entering the air passages. An examination of the air fauces led to 
no explanation of this condition. The epiglottis did not, however, appear to 
completely close the larynx, or to be in its exact position. The tongue was 
movable in all directions, and pressing it down with a spatula caused no incon- 
venience. The hyoid seemed to possess its continuity. No crepitation or ab- 
normal movability could be perceived, and no pain at the root of the tongue 
occurred on attempting to swallow. After repeated examination, the case 
was concluded to be one in which the functions of the nervus vagus had 
undergone great disturbance, or the muscles of the larynx had become torn or 
paralyzed. Medicine and food were administered by mean^ of an elastic tube. 
The patient had a good appetite and slept well ; the pain of the neck was lost, 
and its motion recovered ; a hectic cough, from which he had long suffered, 
alone remaining. After continuing, however, to go on thus well for six days, 



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[Jan. 



the cough increased, the appetite failed, strength was lost, the voice was scarcely 
audible, and in five more days the patient died exhausted. At the autopsy, a 
fracture of the os hyoides was found. One of the large cornua was broken, 
and had become firmly imbedded between the epiglottis and rima glottidis, 
inducing the raised position of the epiglottis, loss of voice, and difficulty in 
swallowing. The fracture was probably produced by muscular action, a cause 
first assigned in a case occurring to Ollivier d' Angers. — Schmidt's Jahrbuch.^ 
vol. Ixviii. 

31. Necrosis of the Cranial Bones after Erysipelas. — M. Larret relates the 
following singular case : In a patient, 52 years of age, the scalp having become 
detached by suppuration, inflammation of the bone followed, and was productive 
of necrosis and separation of the entire bones of the arch of the skull. The 
patient had not presented any signs of disorder of the cerebral system, although 
the membranes of the brain were covered only by integument, so that the move- 
ments of elevation and depression of the brain were perceptible. 

A parallel to this case was seen in that of a patient in Bethlehem Hos- 
pital, who, having been too vigilantly watched, to permit his executing his sui- 
cidal intentions in any other way, laid the back of his head on the fire, and 
completely charred the scalp, destroying the vitality of a large portion of the 
skull. The arch of the cranium became detached, and was deposited by Mr. 
Lawrence in the Museum of St. Bartholomew's Hospital, while the patient was 
living in Bethlehem for several years with only membranous and tegumentary 
covering to his brain. — Lond. Journ. Med., Nov. 1851, from Medical Gazette. 

32. Local application of Wine of Squills in Hygroma. — A Spanish journal, 
La Union, reports, in the March number, a case of hygroma cured by the 
application of compresses Avetted with wine of squills. The patient was a 
woman fifty years old, who had had, for a year, a tumour of the size of a hen's 
egg on the front of the patella. Dr. Serrano, who was consulted, proposed 
iodine injection ; but, as the patient objected, he was led to employ a remedy 
which he had already found successful in a case of hydarthrosis of the knee. 
Cloths dipped in wine of squills were applied, and fixed by means of a bandage ; 
they were frequently renewed. Under this application alone, and without any 
particular regimen, the tumour gradually and completely disappeared in thirty- 
six days. Five months after, there was no return. 

Hygromas, or collections of fluid in the patellar and anconal bursae, must be 
treated by resolvent applications, or by puncture followed by iodine injection. 
Very severe symptoms have been known to follow the operation of opening 
them. The wine of squills, proposed by Dr. Serrano, is perhaps not so effica- 
cious as a local application, as the concentrated solution of sal ammoniac, 
made according to the formula of M. Jobert de Lamballe, in the proportion of 
from sixty to a hundred and twenty grammes of the salt, to five hundred 
grammes of lime-water. Compresses, dipped in the solution, are applied, and 
frequently repeated. It is more likely to be efficacious when the tumour is of 
recent origin. M. Jobert has obtained some very successful results from its 
use. — Jjondon Journ. Med., Oct. 1851, from Journ. de M6d. et de Chirurg. Prat., 
June, 1851. 

33. Inhalation of Chloroform for the relief of Phymosis. — M. Guisard states 
{L' Union MSdicale) that lus son, about three years of age, affected with phymo- 
sis, had been relieved from very distressing symptoms, by inhalation of chloro- 
form. The little patient experienced great agony in passing urine, and the dis- 
tress was so great that he overcame the necessity of performing this function, 
and obstinately refused to relieve his bladder. 

He was placed under the influence of chloroform, so that the phymosed 
prepuce could be incised, and hardly had its effects taken place than the urine 
began to flow, and the rectum was emptied. The next day, the child was 
equally obstreperous, and the same means brought about the same results. M. 
Guisard thinks that these facts may open a new path for the treatment of 
retention of urine or of faecal matter. 



1852.] 



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255 



34. Operation on the Cheelc and Lower Jaw. Inhalation of Chloroform nearly 
fatal. Comments on the use of Chloroform in Surgical Operations. — The Medical 
Times (Nov. 22d, 1851) oontiiins a ciinical lecture, by Edward Stanley, Esq., 
delivered at St. Bartholomew's Hospital, on a case in w^hich an operation was 
performed for the removal of a portion of the cheek and lower jaw, which ia 
of especial interest, from the life of the patient being brought into extreme peril 
by the ill effects of chloroform, and, consequently, Mr. S. remarks, "I very 
nearly had the misfortune to witness an event which, up to the present time, I 
have but imagined with a feeling of horror, namely, the death of a patient 
during an operation undertaken with no idea of immediate danger to life. 

" Joseph Archer, aged thirty-seven, a butcher, residing in the country, in good 
health, and of temperate habits, was admitted into the hospital in September, 
1850, on account of carcinoma in the right half of the lower lip, near the angle 
of the mouth. Mr. Skey removed the diseased portion of the lip without the 
administration of chloroform, and the wound soon became soundly healed. At 
the time of the operation a small hard swelling could be felt in the right cheek. 
About three months afterwards, the cheek was accidentally struck on two or 
three occasions, and then the swelling began to increase. In September, 1851, 
twelve months after the removal of the disease in the lip, the man was again 
admitted into the hospital under my care. The swelling in the cheek had now 
become the size of a walnut, and the integument covering it, was apparently 
about to ulcerate. His general health was good ; the absorbent glands below 
the jaw w^ere not enlarged or indurated ; but the tumour in the cheek adhered 
so firmly to the jaw that it was probable the bone had become implicated in 
the disease. Under these circumstances, an operation to be effective necessa- 
rily consisted in the removal of a large portion of the cheek and probably of 
part of the loAver jaw. On Saturday, the 27th of September, this operation was 
performed. Chloroform was administered through the ordinary inhaler for 
about twelve minutes, without annulling either sensation or voluntary motion. 
Then the mode of administering the chloroform was changed ; it was dropped 
into a piece of lint formed into a hollow cone, and around this, a folded towel 
was laid on the face. A few minutes afterwards I commenced the operation, 
by an elliptical incision through the skin, circumscribing the portion of the 
cheek which I intended to remove. Directly this w^as done my assistants, 
who were watching the pulse at the wrist, reported that it could not be felt, and at 
the same instant, without either stertor or struggle, the countenance of the 
patient changed, and his body sunk upon the operating table apparently life- 
less. It was evident to all around that the patient's life was in immediate and 
imminent peril. Accordingly, instead of continuing the operation, our atten- 
tion was now directed to the means of restoring animation. Cool and fresh air 
was freely admitted to the face and air passages, ammonia was applied to the 
nostrils, cold water was repeatedly dashed on the face and chest, sharp blows 
were struck with the hand upon the epigastrium, and brandy and water was 
slowly poured into the mouth in small quantities, but not repeated until it was 
distinctly followed by the effort of swallowing. Some fluid was now vomited, ap- 
parently the remains of the breakfast the man had taken several hours before the 
operation, and, after a little time, the pulse could be again felt at the wrist ; but 
not until these measures had been continued fifteen or twenty minutes, were 
the circulation and consciousness sufficiently restored to assure us that life was 
safe. Then, with the operation uncompleted, the patient was gently removed 
from the operating table and conveyed to his bad. The question of completing 
the operation was now considered, and I decided on the propriety of postponing 
it to the evening, under the apprehension that for some hours the circulation 
would not be sufficiently firm to resist the influence of the loss of blood which 
must ensue in the further stages of the operation. Accordingly, in the even- 
ing, with the assistance of Mr. Paget, I completed the operation with perfect 
safety to the patient, and, I need scarcely add, without the administration of 
chloroform. As the exposed surface of the jaw did not appear healthy, a semi- 
circular portion of it was removed by means of a key-hole saw, the ^divided 
edges of the cheek being then brought together and kept so by fine pins and 
sutures. The subsequent progress of the case was very favourable. Within 



256 



Progress of the Medical Sciences. 



[Jan. 



three weeks from the operation, the wound had so nearly healed that the man 
would not remain longer in the hospital. The tumour in the cheek, when ex- 
amined after its removal, proved to be of the nature of epithelial cancer; such 
also was the character of the disease previously removed from the lip, 

" It cannot be doubted that in this instance death was very nearly occasioned 
by chloroform. The phenomena were not either the stertor of oppressed breath- 
ing or the sudden stoppage of breathing from the flow of blood into the glottis: 
they were the loss of consciousness and motion followed by sinking of the cir- 
culation, apparently to its complete cessation. The phenomena observed in 
this and in other similar instances, show the prejudicial agency of chloroform 
to be directly upon the heart. Accordingly, the circulation stops before breath- 
ing, and, upon recovery, the circulation returns before the act of breathing, 
circumstances that were well observed in the following case, the history of 
which Mr. Paget has been so good as to draw up for me : ' In a case of tetanus, 
which appeared to be idiopathic, and of which the symptoms were extremely 
severe, a man inhaled about two drachms of chloroform, and in an ordinary 
time and manner was brought under its full influence. I was trying to open 
his mouth, but his jaw was still fixed ; and while still trying, we saw him 
become extremely pale, and then bluish about the lips and nose ; then he began 
to breathe heavily, and frothed at the mouth ; and his pulse, which had been 
irregular during the inhalation of the chloroform, suddenly stopped : his heart 
ceased to beat, and in a few seconds more he ceased, to breathe, and became 
motionless, with his lips flaccid. He was to all appearance dead, and thus he 
remained for about a minute and a half, when again his heart began to act, 
blood returned to his face, and his pulse again became full ; then he began to 
breathe again, and presently he breathed freely. In a few minutes more, he 
had recovered form the effects of the chloroform, and relapsed into the tetanic 
state. While he was apparently dead, various means were used to resuscitate 
him, including sharp blows with the open hand upon his thighs and other 
parts, and these appeared to be useful. It was very observable that the ill 
effect of the chloroform was exercised on the heart more than, and earlier than, 
on the muscles of respiration. His heart ceased to act before he ceased to 
breathe, and his heart recovered, and acted forcibly, so as to propel blood well 
into the capillaries of the face, before he began to breathe.^ 

"Each of the several measures employed in the case which I have related, 
probably did something towards the recQvery of the patient's life. But let us 
suppose that these measures had failed — that by the free and persevering ad- 
ministration of brandy, the pulse at the wrist had not become so distinct that 
life could be considered safe, the patient still continuing to all appearance life- 
less. Under these circumstances, one other measure would, I think, have been 
tried, however doubtful its result, namely, artificial breathing, either through 
a tube passed from the mouth into the glottis, or through an opening made into 
the larynx. Some hope there would be of the success of artificial breathing in 
such a case from the fact that, in axphyxiated animals, it is found to be the 
most direct and sure means of exciting the action of the heart. 

" It will be a question whether, in this case, the ill efiects of chloroform were 
owing to the excessive quantity of it used, or to the mode of administering it, 
or to an unusual susceptibility of its influence. My first impressions upon the 
occurrence of this case were, I confess, of so much alarm at the use of chloro- 
form, that I felt inclined to return to the employment of ether as the anaesthetic 
agent. But, upon narrowly viewing all the circumstances, I now adopt the con- 
clusion that, in this instance, the ill effects of the chloroform are to be attributed 
to the mode in which it was administered, and which I am disposed to explain 
in the following way. It is to be observed, that not until the ordinary inhaling 
apparatus wos changed for the hollow cone of lint moistened by the chloroform, 
did the alarming symptoms appear, and I cannot but think that, from the lint 
thus imbued with chloroform, the vapour was inhaled in too concentrated a 
form, not sufficiently mixed with fresh air to be drawn into the air-passages of an 
individual who had already inhaled it through the ordinary apparatus for twelve 
minutes. 

" Observation warrants the opinion that there is not any marked difference 



1852.] 



Surgery. 



257 



in the effects of chloroform upon different persons, although the time required 
to produce complete anaesthesia varies greatly, and the symptoms are not always 
the same which precede the suspension of consciousness and voluntary motion. 
Provided that due caution be used, chloroform may be administered with equal 
safety in infants and in advanced age ; but in infants, the action of the con- 
centrated vapour of chloroform is so quick, that great care is necessary in 
respect to the quantity of it used and to the mode of administering it, otherwise 
there will be danger of the action of the infant heart stopping simultaneously 
with the cessation of motion and sensation in the rest of the body. 

"Experience has not fuimished evidence against the use of chloroform in 
instances of extreme debility, the consequence of long suffering from diseases 
of the joints or other organs. Although in such individuals the pulse may be 
extremely frequent and feeble at the time of the operation, yet it has not ap- 
peared that the chloroform is more likely to affect the action of the heart than 
when administered in opposite conditions of the system. Nor has it appeared 
that the use of chloroform should be forbidden when the nervous system is 
depressed by the shock of a severe injury, as a lacerated limb, compound frac- 
ture, or dislocation. Such, at least, is my impression from the observation of 
its effects in these cases, 

"An empty stomach is essential, preparatory to the administration of chlo- 
roform. Our rule in the hospital is, that the patient should take only a light 
breakfast several hours previous to the time of the operation. When, from 
inattention to this point, tlie chloroform has been administered upon a full 
stomach, the usual result has been that, shortly after the commencement of the 
inhalation, repeated ejections of the contents of the stomach have ensued, occa- 
sioning much exhaustion and distress to the patient. After the fullest and 
most protracted administration of chloroform, no other attention is ordinarily 
required than the abstinence from food for five or six hours. If food is taken 
within this period, it will probably be rejected. Headache and continued irrita- 
bility of stomach are the occasional ill consequences of chloroform, but they 
usually subside of themselves. If these symptoms continue with depression of 
the pulse, it may become necessary to administer brandy, ammonia, liquor opii, 
sedatives, etc. But rarely indeed are these measures required. Almost con- 
stantly, on visiting the patient who has just undergone a severe and protracted 
operation, I have found the pulse of its natural fulness, force, and frequency. 
The general result of the use of chloroform in operations, is to leave the patient 
in a state neither of debility nor depression. 

" All the evidence to be gathered on this subject, leaves my mind satisfied of 
the propriety of continuing the use of chloroform in operations. I do not find 
sufficient grounds for the substitution of any other angesthetic agent in its place. 
Next to chloroform, sulphuric ether appears to be the most eligible anassthetic 
agent. The advantages of chloroform are, that it acts most quickly in annulling 
sensation and voluntary motion, and that it does so without irritating the air- 
passages or causing distress in any other way ; its disadvantages are, that its 
narcotizing effects soon subside, and that it tends to weaken, that it may even 
stop the action of the heart. Sulphuric ether almost constantly excites cough- 
ing, and a sense of suffocation ; its narcotizing action is usually slower than 
that of chloroform, but it endures longer. The quick subsidence of the narco- 
tizing effects of chloroform renders it necessary to repeat the inhalation, and 
frequently at short intervals ; but, if this be done Avith proper attention, there 
need be, I am willing to believe, no apprehension of the stoppage of the pulse. 
This attention should be directed to the quantity of chloroform used, to the 
mode of using it, and to its influence upon the pulse. It is desirable not to 
change the mode of inhalation ; but, if this be done, it should be so managed 
that, when the patient has been long submitted to the agency of chloroform 
without the desired effect, the mode of inhalation should not be changed for one 
which will suddenly apply to the air-passages the concentrated vapour of two 
or three drachms of chloroform, for this will be accompanied by the danger of 
instantly annihilating the action of the heart. Such, as has been already 
stated, was, as I believe, the error in the mode of administering the chloroform 
to the patient, whose case I have related ; and to some such defective proceed- 



258 



Progress of tlie 3Iedical Sciences. 



[Jan. 



ing I am disposed to attribute the fatal effects of chloroform in other instances 
which have been recorded. The individual who administers chloroform, should 
be sufficiently experienced in practical medicine, to be capable of quickly ap- 
preciating changes in the pulse. Whilst the fingers of one hand are applied to 
the patient's wrist, the other hand should regulate the application of the inhaler 
to the patient's face. The test of sufficiency of the influence of chloroform 
usually relied upon, is the suspension of voluntary motion ; but in some indi- 
viduals, even before voluntary motion is suspended, sensation is sufficiently 
annulled to allow of the operation proceeding without pain. There has been 
ample experience of the safety of using chloroform in operations which were 
necessarily protracted. In a youth, aged fifteen, I removed an osseous exos- 
tosis from the neck of the humerus. The full influence of chloroform was 
maintained an hour and a quarter without occasioning the least derangement 
of his system ; and, in another case, chloroform was safely administered for an 
equally long period to a member of our profession, during the removal of a 
tumour situated upon the parotid gland, but beneath the primary branches of 
the portio dura, and, consequently, I had to detach each branch of the nerve 
separately from the tumour, and to draw all the branches aside, whilst the 
removal of the tumour was completed : all of which could not have been accom- 
plished without the aid of chloroform, for, during the restlessness attendant on 
severe suffering, the nerves could not have been separated from the tumour 
without the division of some of them, and the consequent paralysis of the face. 
If there should be mistrust in the prolonged use of chloroform, it has been rea- 
sonably suggested, that, after the first narcotization by chloroform, it may be 
changed for sulphuric ether, which will require less frequent repetition, as its 
effects endure a longer time, with, it has been considered, and if truly, the im- 
portant advantage of not tending, in the same degree, to weaken the action of 
the heart. 

" There is not, I believe, any good ground for the opinion that the use of 
chloroform in operations interferes with the healing of the wound. That 
chloroform, by preventing pain, saves the system from the shock of the opera- 
tion, I have no doubt ; moreover, the smarting of wounds which, often endured 
for hours, is scarcely ever complained of after the administration of chloroform, 
and in amputations, when chloroform has been inhaled, the painful twitchings 
and jumpings of the stump, so distressing to the patient, scarcely ever occur. 

" The circumstances of the case which I have related, added to the knowledge 
of other cases which have been communicated to me, show clearly the line of 
conduct to be pursued whenever, during an operation under chforoform, the 
pulse sinks so that it cannot be felt, accompanied by a sudden collapse of the 
patient, so that he appears to be lifeless — it is to suspend the operation, and 
not resume it for several — say six or nine hours, in order that sufficient time 
maybe allowed for the heart to regain its action so firmly that there would not be 
danger of its failing again, from the loss of a small quantity of blood, in com- 
pleting the operation." 



MIDWIFERY. 

35. Duration of Pregncmcy. — Dr. Murphy read (11th Oct.) a paper on this 
subject, which is interesting both in a physiological and medicological point 
of view, before the Medical Society of London. 

Two questions are proposed by him for consideration : 1st. Is the duration 
of pregnancy a fixed or a variable period? and, 2d, if it be decided that it is a 
variable, AVhat are the limits of its variation ? The usual mode of calculating 
the term of pregnancy is by dating from the last period of the menses to the 
time of delivery, the gross results being corrected by deducting as many days 
as is supposed necessary to avoid error. Some, believing that conception may 
take place at any time, deduct one-half the menstrual interval ; while those 
who consider that conception can only take place at the menstrual period, date 



1852.] 



Midwifery. 



259 



either from the last catamenia, or from that which should have happened, but 
for conception. This estimate being compared with the period of quickening, 
a result is obtained sufficiently accurate for ordinary practical purposes; but 
not precise enough for legal evidence. Other indications have, therefore, been 
sought for. Peculiar sensations are experienced by some women at the time 
of conception ; some cases of this kind, described by Dr. Montgomery, would 
tend to fix the duration of pregnancy at two hundred and eighty days. In 
oth6r cases, it has been ascertained by the date of a solitary intercourse, 
which, of course, fixes the date of conception ; the same period of two 
hundred and eighty days is, from such cases, given by Sir C. Clarke and others, 
and from these facts many are inclined to regard that period as the correct 
duration of pregnancy. To this opinion, however, Dr. Murphy does not sub- 
scribe, as these cases are comparatively few in number, and, if the rule were 
different, might easily form an exception to it without invalidating it. He 
would, therefore, call in the aid of statistics for the solution of the problem ; 
this he commenced some years since, at the University College Hospital, when 
forming a register of obstetric cases. The following method Avas adopted : 
When a letter for attendance was applied for, an inquiry was made as to the 
catamenia, the age of the applicant at its commencement, its period, and its 
last appearance. With regard to the last question, some could only give the 
month, others were precise as to the date, and some were too irregular to date 
from. The last were excluded from the inquiry, as, for instance, some who 
were nursing either had no change or a very irregular one ; others had been 
always irregular before pregnancy, and, therefore, could not be depended on ; 
and again, with others, the catamenia had evidently continued after conception ; 
all these were excluded as the others were noted, and when delivery occurred, 
that also was noted, the interval between the two giving the gross duration of 
pregnancy, which was afterwards corrected, so as to make as near an approach 
to accuracy as possible. Of these cases, some time back, a table of one hundred 
and eighty-six was formed. The corrections were made as follows: If the 
period exceeded two hundred and eighty days, and the woman had given the 
exact date when she was last unwell, the whole menstrual interval was 
deducted; so, if the whole period were three hundred and twenty-eight days, 
and twenty-eight days were the menstrual interval, three hundred days would 
be regarded as the true duration. It was considered that the woman might be 
in error, and it was thought safer to suppose that conception occurred just be- 
fore the catamenia which had been arrested. Subsequently two hundred and 
eight}'^ days were regarded as the true period, and in any cases that exceed, the 
menstrual period is deducted, the result being presumed to be accurate. From 
his records of nine hundred and sixty-five cases, Dr. Murphy has formed four 
tables: 1st, those in which the duration of pregnancy exceeded two hundred 
and eighty days, including three hundred and three cases ; 2d, those that are 
exactly that period, including three hundred and seventy-eight cases ; 3d, those 
between two hundred and sixty and two hundred and eighty days, including 
two hundred and one cases ; and 4th, those below two hundred and sixty, in- 
cluding eighty-three cases. The 4th, or last table, he (Dr. Murphy) looks upon 
as instances of premature labour. From these tables he gathers that the dura- 
tion of pregnancy is not a fixed but a variable period, as in the lower animals, 
varying, however, only within certain limits. Those limits are not yet ascer- 
tained. He regards two hundred and sixty days, or thirty-seven weeks, as the 
shortest period ; he has attended mature infants born at that date. The longest 
period is yet subjudice, the cases in the first table being yet under examination, 
and requiring correction. 

The paper concluded with the details of a case of protracted pregnancy, par- 
turition being delayed till six months and a half after quickening, i. e. two 
months longer than usual. — Medical Times, Oct. 18th, 1851. 

36. On Kiestein. — In consequence of the discrepancy of opinion which pre- 
vails among observers as to the value to be attached to the appearance of the 
urine termed Kiestein, as diagnostic of pregnancy. Dr. Veit has, during a year 
and a half, been conducting a series of experiments at the Halle Lying-in In- 
No. XLV.— Jan., 1852. 18 



260 



Progress of the Medical Sciences. 



[Jan. 



stitution. He has esamined for this purpose the urine of ten men, of four non- 
pregnant females, and of forty-eight women in various stages of pregnancy. 
He comes to the same conclusions as Plofle ( Chemie und Mikroshop am Kran- 
kenbeite) and, recently, Lehmann, viz., that the so-called pellicle of Kiestein is 
no peculiar matter at all, and is not of the slightest value as a sign of preg- 
nancy. In urine of both non-pregnant and pregnant women, pellicles are 
formed containing vibriones, and frequently the triple phosphate; the chief 
difference between the respective urines being, that in that of pregnant women, 
alkaline, and in that of non-pregnant women acid, reaction more frequently 
manifests itself. This may in some measure depend upon the greater concen- 
tration of the urine in pregnancy, and the larger proportion of mucus mixed 
with it, as a consequence of the changes induced in the condition of the mucous 
membrane of the bladder by the passive hypersemia of that organ during preg- 
nancy. Persons partaking of a more nitrogenous diet than did the poor pregnant 
women whose urine was examined, might furnish different results in this re- 
pect. — Med.-Chir. Rev. from Zeitsch.fur Geburt., vol. xxx. 

37. Indian Hemp : its power of increasing JJieriiie Contraction during Labour. 
— Dr. Alexander Christisox, in a series of papers upon the Natural History, 
Action, and Uses of Indian Hemp, has made a most important addition to our 
knowledge of therapeutic agents. He establishes its remarkable power of in- 
creasing the force of uterine contraction during labour. After subjecting seven 
cases, he makes the following remarks: — 

" There can be no doubt that the intensity of the pains was greatly augmented 
by the hemp, except in the last case, where, after the effects of the first dose 
passed off, no action followed the repetition of it. This case was an exception 
to all the others. 

"It is worthy of remark, that in none of these cases were the ordinary phy- 
siological effects produced ; there was no excitement or intoxicating action, and 
there did not seem to be the least tendency to sleep in any of them. 

" In conclusion, I may state what appears to be the most obvious difference 
between the action of ergot of rye, and that of Indian hemp. First — While 
the effect of ergot does not come on for some considerable time, that of hemp, if 
it is to appear, is observed within two or three minutes. Secondly — The action 
of ergot is of a lasting character, that of hemp is confined to a few pains shortly 
after its administration. Thirdly — The action of hemp is more energetic, and 
perhaps more certainly induced, than that of ergot. 

" There appears little doubt, then, that Indian hemp may often prove of essen- 
tial service in promoting uterine contraction in tedious labours. 

"More extended experience will show how far these effects maybe depended 
on, and to what cases hemp is most applicable. 

" Mode of Administration. — Indian hemp may be administered in several 
wa3'^s. The extract, in the form of pill, produces the most gradual effect, and 
the disagreeable taste of the solution is avoided ; but its action in this form is 
very uncertain. The following emulsion has been recommended: A scruple 
of the extract rubbed in a warm mortar with a drachm of olive oil, to which are 
added half an ounce of mucilage, and seven ounces and a half of distilled water 
(Bromfield). But the simplest method is to use the tincture, which should be 
dropped into a little water, and immediately swallowed. The water may be 
sweetened with sugar, or an aromatic, such as compound tincture of cardamoms, 
may be added. The usual strength of the tincture is three grains of the extract 
to a drachm of rectified spirit. 

" The extract may be given in doses of one to six grains ; the tincture in doses 
of ten to thirty drops, for ordinary purposes. Less than thirty drops is of little 
service in promoting uterine contractions ; and greatly larger doses, as much 
as one or two drachms repeatedly, must be used in the treatment of tetanus, in 
which disease there is very great tolerance of the vQm.Q&j."—Lond. Jour. Med., 
Nov. 1851. 

38. Peculiar form of Thrombus occurring during Labour. — There are two situ- 
ations in which the formation of a thrombus or bloody tumour during natural 



1852.] 



Midwifery. 



261 



labour is a matter of common observation — namely, on the head of the child, 
and at the vulva of the woman. Dr. AYm. F. Montgomery has satisfied him- 
self that there is a third variety, where the elFusion of blood takes place in the 
tissue of the uterus, near the os uteri, and more especially in the anterior lip 
of that organ. The first time that this matter attracted his attention in prac- 
tice, was in the following cases : — 

"Mr. S. requested my attendance on his wife, on lltli March, 1830, at ten 
P. M,, she being then in labour. The night before she had diarrhoea and some 
discharge of blood from the vagina ; she had six children by a former marriage, 
and her last was now five years old. I found her with labour established, and 
with some hemorrhage, but not much. One part of the lower portion of the 
cervix, towards the right side, felt very prominent, thickened, and spongy, so 
as most strikingly to resemble a portion of the placenta ; and it appeared to me 
that it was from this part the hemorrhage was proceeding. The head pre- 
sented naturally ; the labour progressed favourably, and as the descending head 
came to press more forcibly into the os uteri, and on the spongy tumour, its 
contents were discharged; the hemorrhage ceased, and did not again return, 
and at half-past twelve o'clock a male child was born, healthy and vigorous. 
The placenta came away in about ten minutes. There was no further hemor- 
rhage or other unfavourable symptom, and the lady recovered Avell. Mr. S. 
was a medical man, and, seeing the hemorrhage, he became anxious, and made 
an examination, when he was greatly alarmed at feeling, as he thought, the 
placenta at the os uteri, and immediately sent for me. 

"After hearing his report, I examined the patient, and at the first moment 
thought his account was only too correct; but a little further examination 
easily satisfied me of the true state of the case, because it was clearly evident 
that the tumour resembling the placenta Avas not merely applied to the inner 
surface of the uterus, but was identified with the substance of the organ, so 
that it was impossible to insinuate the point of the finger between them, while 
it could be readily passed behind or partially around. To those who may not 
have met with this state of the parts, I would beg leave to say, that the resem- 
blance of this tumour, when in the form in which it occurred in this case, to 
the placental structure, is sometimes so close as very readily to deceive an in- 
cautious examiner. The circumstances under which we meet with this condi- 
tion in practice are generally as follows : About the time when the os uteri is 
more than half dilated, especially if the waters have already been evacuated, 
we find that the anterior lip gets gradually, but pretty quickly, fuller, thicker, 
and more prominent, and, instead of yielding readily before the pressure of the 
head, and slipping away upwards, it continues to descend as the head is forced 
downwards ; and if we try with the point of the finger to push it past the head, 
and out of the way, we do not succeed; an unexpected delay now takes place, 
and a labour which we had every reason to hope would go on quickly, and be 
completed within a shoit time, is protracted for perhaps two or three hours, or 
even more, and the patient's pain increased both in character and duration. 
At length the swollen labium diminishes, suddenly recedes, and disappears, 
and very often, at the same moment, some blood is discharged, generally of a 
deep rich colour, and now the retarded head descends more quickly. 

"I do not wish to be understood to say that the swollen lip in such cases al- 
ways bursts and discharges its contents, for such is not the fact, but that this 
is frequently the result I feel quite assured. I had recently (10th October. 
1850) an opportunity of seeing this condition of the anterior lip of the os uteri 
during labour. The lady had four children, and her labour was in every respect 
satisfactory. Shortly after the discharge of the liquor amnii the pains became 
urgent, and the anterior lip of the os began to swell, and immediately, as in all 
other instances of thrombus that I have met with, the propulsive power of the 
pains was at once impaired, although they continued strong, and returned at 
short intervals ; but still the swollen lip resisted the passage of the head, or at 
least did not yield, and continued to be pushed down with it, until with each 
pain it protruded under the arch of the pubis, of a deep purple colour, like that 
of black currant jelly ; suddenly it disappeared, and one or two ounces of deep, 
rich coloured blood flowed away; the pains became in a few minutes much 



262 



Progress of the Medical Sciences. 



[Jan. 



more efficient, and the labour was soon happily completed. The lady recovered 
well. Is this accident an occurrence of little moment beyond the temporary 
delay and increased sufiering which it causes ? or is it one that may have dan- 
gerous results? are questions of no inconsiderable importance. 

"Were I to judge from my own experience alone, I should be bound to say, 
that I had found both forms of thrombus, the external and the internal, free 
from fatal, though liable to produce serious consequences; but the experience 
and observations of others have shown that the bursting of bloody tumours, 
wherever situated, has been often a source not alone of great danger, but some- 
times even of death. I have already alluded to the occasionally pernicious na- 
ture of the hemorrhage accompanying the thrombus of the external labium, and 
I recently heard the particulars of a case, and examined the uterus after death, 
in which, I think, death resulted from a thrombus in the substance of the cer- 
vix uteri. 

"The case to which I allude was brought under the notice of the Obstetrical 
Society by Dr. George Johnston. The woman had an easy and apparently safe 
labour, with a breech presentation, and for three or four days afterwards went 
on perfectly well ; but on the fifth day, greatly to the surprise of those who saw 
the patient, and found the uterus well and firmly contracted, a profuse hemor- 
rhage took place suddenly, and the patient sank within an hour and a half. 
After death, it was ascertained that there was in the substance of the cervix 
uteri, close to the os, at the left side, a distinct cavity, capable of containing a 
small orange, into which opened the mouths of several blood-vessels. 

" After a careful inspection of the parts, I felt no doubt that this was an in- 
stance of the accident I have been describing; that in fact a thrombus had 
formed, the cavity of which was filled by a coagulum; that the thin stratum 
of uterine structure, or perhaps only mucous membrane and areolar tissue, in- 
terposed between the cavity of the thrombus and that of the uterus, was gradu- 
ally attenuated, and at length burst, or sloughed away, allowing, of course, the 
coagulum to escape, and the open blood-vessels suddenly to pour out a torrent 
of blood, under the overwhelming influence of which life was extinguished 
within the awfully brief space of an hour and a half. It is to be observed, that 
in the case of thrombus of the external labium, related at the commencement 
of these observations, the slough separated on the fourth and fifth days ; and 
here, in the case now before us, the fatal gush of blood took place just at the 
same interval after labour. It is but right to say of such a case, that it exhibits 
one of those unforeseen but perilous accidents against which no human care or 
caution could guard, or human skill be always available to save the patient's 
life. 

"In the month of July of last year, I saw a case which I have great reason to 
believe was of the kind now under consideration. 

"A lady affected with varicose veins, which extended all up the lower ex- 
tremity, and could be traced into the vagina, was delivered, after a natural and 
favourable labour, at midnight; but shortly afterwards a fearful rush of blood 
took place very unexpectedly, for the uterus was loell and firmly contracted. So 
great Avas the hemorrhage, that complete prostration was immediately pro- 
duced, and when I saw her, she was cold and pulseless, nor had she any return 
of pulsation in the radial artery for six hours and a half from the time of the 
sudden hemorrhage, and during a part of that time the action of the heart 
could neither be felt nor heard. All this time the uterus remained perfectly 
contracted, but in the situation of the anterior lip its substance felt as if broken 
up into a soft pulp, the consequence, as I believe, of the formation and rupture 
of a bloody tumour. To our great joy, she ultimately rallied under the treat- 
ment adopted, and completely recovered. 

" I believe the formation of a thrombus at or near the os uteri, its rupture, and 
consequently open state of some vessel or vessels in the cavity thus formed, is 
very often the real cause of those hemorrhages after the birth of the child and 
expulsion of the placenta, where the uterus is found to be well and firmly con- 
tracted ; and it is to be recollected, that just where the thrombus forms is pre- 
cisely the situation in which the contractile power of the organ is most feeble ; 
and should it happen towards either side, it is then close upon the very part 



1852.] 



Midwifery. 



263 



where the blood-vessels send in the largest supply to the uterus. And I would 
say, that while we should neglect no general or subsidiary means to check the 
hemorrhage, or secure the patient from its dangerous effects, onv greatest secu- 
rity, under such circumstances, will be obtained by plugging the vagina, while 
at the same time, we take the necessary precautions against allowing the ute- 
rus to relax and become distended with blood. 

" If the occurrence of this affection has been described or noticed by any for- 
mer writer, I am not aware of it; but in the writings of two of our most emi- 
nent authorities in practical midwifery, I find in each a passage distinctly 
bearing upon the view I have here put forth, and, as far as they go, tending to 
confirm its truth. At p. 271 of his Irdrodnction to Midwifery (5th edit.), the 
admirable Denman says: " The uncoloured mucous discharge from the vagina, 
which pretty generally occurs before labour, on its accession is usually tinged 
with blood, or a small quantity of pure blood is discharged. This sanguineous 
discharge, which varies in quantity and appearance in different women, is 
popularly called a show ; and it happens more particularly at two periods of a 
laboui' — when the os uteri begins to dilate, and when it is finally dilated. In 
the first instance, it is probably occasioned by the separation of a few of those 
vessels by which the membrane which connects the ovum to the uterus was 
originally bound ; and in the second case, by the efi'usion of some blood before 
extravasated in the substance of the os uteri ; for this part, in some cases, acquires 
an uncommon thickness from that cause, independent of any oedetyiatous or inflam- 
watory tumefaction.'' And Dr. Burns observes, at p. 460 of his Principles of 
Midwifery (9th edit.) : " In tedious labour the os uteri, and even the cervix, 
sometimes becomes swelled, as if blood were effused into the substance.'' 
Where such a condition is recognized during labour, we shall show our wisdom 
by interfering as little as possible with it; by abstaining from attempts to get 
the gorged lip of the os over or past the head ; and when the head does descend, 
and is expelled, we should be more than usually slow to withdraw the body of 
the child, more than usually careful to secure complete uterine contraction, and 
more than usually watchful of the state of our patient after all is over; although 
we must, at the same time, acknowledge the painful truth, that with all tbe 
care and caution that the most anxious circumspection can prompt to the adop- 
tion of, an accident of this kind may take place under circumstances of which 
we have no intimation, until alarmed by the urgent danger of our patient, or 
struck aghast by her unexpected and untimely death.'' — Dublin Med. Fress, 
Aug. 27, 1851. 

39. The Left Arm and Hand of a Child found in a Sfaie of Putrescence, from 
Strangulatian, the Funis being tightly bound round it at the upper part. — Mr. A. 
Owens records, in the Provincial Med. and Surg. Journ. (Oct. 15, 1851), an in- 
teresting^example of this, which he has met with in a woman, the mother of four 
children, to whom he was sent when she was miscarrying in the seventh month 
of her fifth pregnancy. Mr. 0. found the membranes ruptured, a large discharge 
of the liquor amnii to have taken place, and the labour pains occurring evej-y 
fifteen or twenty minutes. There was not any flooding, neither could Mr. 0., 
by examination, feel the child. She continued in this condition for another six 
hours, when the pains ceased, and she went on with her pregnancy to the full 
period of gestation, without any other inconvenience besides what she termed 
a constant " drippling of the waters." On the 27th of July, two months after, 
Mr. 0. was again hastily summoned, and found the pains strong and regular, 
the OS well dilated, but no portion of the child to be arrived at by manual exami- 
nation. He therefore gave her a dose of the pulverized secale cornutum, 
which had the effect of increasing the strength of the pains ; and in less thau 
half an hour he discovered a hand outside of the vagina, and the head tightly 
wedged against the brim of the pelvis. All attempts to return the hand, or to 
pass his own, so as to turn the child, were perfectly useless; and he therefore 
resolved to leave the management of the case for the next half hour to nature, 
when, much to his satisfaction, as if under some violent and sudden impulse, 
the uterus discharged the whole of its contents with such force that the foetus 
and placenta both came away en masse. The child was dead, apparently not 



264 



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[Jan. 



many hours, but the entire of the left upper extremity was in a shrivelled, livid, 
and putrid condition, the funis tightly bound round and imbedded in the upper 
part of it, just belovr the insertion of the deltoid ; in fact, the limb did not 
appear much more than half the size of its fellow on the other side. The 
mother had a good getting up, and seemed none the worse two days after- 
wards. 

40. Spurious Menstruation in newly-horn Infants. — Dr. Matthews Duncan 
related to the Edinburgh Obstetrical Society (June 25, 1851), the following very 
rare cases. All forms of hemorrhage from mucous surfaces in newly-born 
infants were very seldom met with. Cases of epistaxis, of hasmatemesis, and of 
bloody evacuations from the bowels, did occasionally occur within the first few 
days after birth ; and not a few such cases had been recorded by various authors, 
who, however, were very rarely found to allude to the form of hemorrhage under 
consideration. 

Authors had attempted to account for all these forms of hemorrhage at so 
early a period of life by ascribing them to the great and rapid change produced 
in the child at birth by passing from the condition of an intra-uterine foetus, 
with a placental circulation, to that of an infant with a pulmonary circulation, 
and respiring air. If this were ever the cause, it certainly was not so always ; 
for in many cases there was satisfactory evidence that the bleeding had com- 
menced while the child was still in utero, and consequently before the change 
above mentioned had taken place. 

The only case Dr. D. had seen occurred in a fine, strong, healthy child, the 
first-born of its mother. It was a case of head-presentation, and the labour was 
easily terminated. The mother was a young healthy woman, of sanguine tem- 
perament. In her, menstruation recommenced four weeks after delivery, and 
recurred regularly during the whole period of nursing. The vaginal discharge 
in the infant appeared the day after its birth, and had all the appearance of 
menstrual blood. It continued for six days, every napkin on removal bear- 
ing a large stain of the blood. About the fourth day the mammae began to 
swell and inflame. After the vaginal discharge ceased, the swelling of the 
mammae disappeared. 

The following case occurred recently in the practice of Dr. Cunningham of 
Currie, who kindly communicated it to Dr. D. The child was born naturally 
and easily, the head presenting. It was two days old when the discharge from 
the vagina commenced. This appeared to be venous blood, from the colour, 
and was in considerable quantity (perhaps a drachm every time the cloth was 
removed). It continued for four days. The mammae of the child were enlarged 
and indurated at the time ; but when the discharge stopped, the swelling dis- 
appeared. 

The third case of bloody vaginal discharge (see Gaz. MM., 1835, p. 248) oc- 
curred in a strong child, born of a healthy young woman. After it was three 
days old, a slight loss from the genital organs Avas observed, the blood flowing 
drop by drop. In this way it continued for three days, and then became more 
and more watery. On the fourth day, some drops of pure blood came away, 
and then the discharge ceased. It had the appearance of menstrual blood. 
Five days afterwards the mammas became inflamed. Subsequently the infant 
had good health. 

These cases seemed to arise, not from any extraordinary circumstance in the 
labour, or disease in the infant, but were apparently a consequence of san- 
guineous engorgement of the sexual system of the newly-born infant. 

In all the cases the labour was easy. The children were born with the head 
presenting. In none of the cases did the breech of the child suffer any violence. 
No disease existed in mother or child; nothing morbid was discovered in the 
genital organs of the children. The discharge floAved for from four to six days, 
and then ceased spontaneously. After the vaginal discharge, there supervened 
engorgement and inflammation of the mammas; and although engorgement 
of the mammae of both male and female children is of frequent occurrence, still 
its coincidence with the vaginal discharge in these cases, and its apparent con- 
nection with it, could scarcely be looked upon as merely accidental. — Monthly/ 
Journ. Med. Sci., Nov. 1851. 



1852.] 



Midwifery. 



265 



41. Cases of Purulent Infection. — Dr. Charlton communicated to the New- 
castle and Gateshead Pathological Society (Aug. 1851), some cases of puerpe- 
ral infection. 

" It is now, we believe," he remarked, " generally acknowledged that erysipe- 
las and puerperal fevers may be reciprocally produced ; that, in the words of 
Dr. Murphy, of University College, they are convertible diseases, which may 
be conveyed either directly from patients, or indirectly by means of the medi- 
cal attendants and nurses. We have met with numerous examples where a 
surgeon, after attending a case of erysipelas, has been terrified by the sudden 
appearance of several cases of puerperal fever in the females he attended in 
childbirth ; and, on the other hand, it has often been recorded that the nurses 
and attendants on a case of puerperal fever have been attacked with dangerous 
and fatal erysipelas. That erysipelatous contagion was the cause of death in 
one of the fatal cases we have here to record, there can, we think, be little 
doubt ; but the converse proposition, that the puerperal condition, or rather 
purulent infection after delivery, produced erysipelas and rheumatic fever in 
the other parties affected, will be less easily proved, though we own ourselves 
to be convinced of such having been the case. 

" As the full record of all the various symptoms observed in the eight cases 
here alluded to would occupy too much of the time of the Society, we have en- 
deavoured to abbreviate the details, and to present only the most remarkable 
features of each case. 

" Mrs. M., ast. 31, of full habit and powerful frame, was confined on the 17th of 
December, 1850, of a healthy child. Her confinement was unattended with 
any abnormal symptoms, except that the lochial discharge was for a considera- 
ble time extremely fetid ; and she suffered, as she had done for two months 
before her confinement, from irritation at the neck of the bladder. She soon 
recovered so far as to get down stairs, when about the end of December or the 
beginning of January, she was attacked with shiverings, and became much 
depressed in spirits. She attributed the rigors to having stood in a passage 
exposed to a draught of air from an open door. Twenty-four hours after the 
rigors first came on, copious perspiration followed, and the feverish symptoms 
partially subsided. The teeth of the lower jaw now became very tender, and 
a large swelling formed at the root of one of the molars of the right side ; this 
did not suppurate, though for some days it appeared as if it would do so, and 
then gradually subsided. As it disappeared, and about a week after the first 
rigor, another similar attack of shivering, depression, and loss of appetite, 
occurred. Eight days after this she began to complain of pain in the right 
thigh and in the back, and soon after a copious menstrual discharge came on, 
though she still was suckling her infant, and had a plentiful supply of milk. 
Mrs. M., however, had always menstruated regularly while suckling her chil- 
dren. The pain in the right thigh, which was not accompanied with any per- 
ceptible swelling, continued for some days, and shortly after she complained of 
pain in the left side immediately below the ribs, extending back from thence to 
the spine. This was soon accompanied with cough and shortness of breath, 
and the pulse rose to 120. The pain abated under the internal administration 
of calomel, antimony, and opium, with blisters applied to the affected part ; but 
the affection then shifted to the left thigh, and, after remaining fixed there for 
a few days more, it migrated to the left arm, and then in a day or two ceased 
altogether, while the secretion of milk was gradually arrested at the same 
time. 

"On the 6th of February, 1851, the pulse again rose ; she perspired copiously 
during that and the following day, and complained of great debility and loss of 
appetite. At this time it was observed that she had a remarkably heavy, sunk- 
en look, and was depressed in spirits. On retiring to rest about 10 P. M. on 
the 7th of February, she suddenly fell down on the bed in what was at first 
supposed to be a state of syncope ; the pulse became extremely small ; the res- 
piration slow and laboured, though not absolutely stertorous ; and there were 
frequent relapses into syncope. Stimulants were now administered, but could 
only be swallowed by half-teaspoonfuls at a time, as otherwise they constantly 
got into the trachea, and produced threatenings of asphyxia. The head and 



266 



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[Jan. 



neck were covered with copious perspirations. About one A. M. she vomited a 
quantity of undigested food, and after that was less faint. Paralysis of the left 
leg and arm was first observed on the evening of the 8th, twenty hours after 
the first attack, previous to which time she had moved both arms and both legs 
freely. The subsequent symptoms of this case were those of apoplexy ; the 
left arm and leg never recovered their power ; and though, by active treatment 
the immediate danger was obviated, she lingered in a most melancholy condi- 
tion, both as to mind and body, for five months, when she sunk apparently 
from debility without any fresh apoplectic seizure. We have been particular 
in the details of the earlier symptoms of this case, because at our first seeing 
the case about mid-day on the 8th of February, it was the unanimous opinion 
that the cause of the symptoms was probably some purulent infection remain- 
ing in the system after delivery, till the more decided apoplectic phenomena 
supervened some hours later. 

" The condition of Mrs. M. required, of course, the closest attendance from all 
parties ; but due attention Avas paid to cleanliness, and to the due ventilation 
of the large airy apartment in which she lay. 

" On the 14th of February, one of Mrs. M.'s children, set. 6, who had never 
been in his mother's sick room, was attacked with sore throat, and high fever, 
with vomiting and headache. It was thought that he was about to take scarlet 
fever ; but after several days the symptoms subsided, though he remained un- 
usually weak and delicate for some time after. 

" The mother of Mrs. M., Mrs. B., set. 54, a woman of very strong constitution 
and great powers of enduring fatigue, had passed twelve days and nights at 
the bedside of her daughter, hardly taking any sleep during that period. At 
the end of this time, or about the 19th of February, Mrs. B. began to complain 
of sore throat, with swellings of the glands of the neck, with much restlessness, 
and some tendency to low wandering delirium during the night. There was 
also severe pulsating pain of the head, a furred tongue, and an exceedingly 
fetid breath, followed by nausea and vomiting. These symptoms soon assumed 
the form of erysipelas, the inflammatory action commencing about the right 
ear and over the mastoid process of that side, and thence passing over the scalp 
and towards the neck. Mrs. B. was ill for about a fortnight, when the inflam- 
mation subsided, and she slowly recovered her strength. During her illness, 
the husband of Mrs. M., a strong healthy man, of almost gigantic frame, and 
who had hitherto enjoyed excellent health, had taken the place of Mrs. M.'s 
mother in attending on his wife. From the commencement of Mrs. M.'s illness, 
he had rarely enjoyed a night of refreshing sleep, and had, as might naturally 
be supposed, sufiered intense mental agony and anxiety. About the I7th of 
February, or nearly at the time that Mrs. B, first became ill, he began to com- 
plain of swelling and pain in the right side of the fauces, so as to make the act 
of deglutition difficult ; the fauces on that side were red, but there was little 
fever or loss of appetite. By the 21st of February his throat was much better, 
and he resumed his attendance on his wife, and remained for nearly forty-eight 
hours at her bedside, lifting her repeatedly, and then shifting her position, as 
she was extremely restless, and seldom remained more than a few minutes 
without requiring to be moved. At the end of this time he became completely 
exhausted, and now complained of pain on the opposite side of the fauces, 
which on examination were found to be red and swollen as before. He now 
became extremely alarmed about himself, and was impressed with the idea that 
he would not recover. There was at this time but little fever, but deglutition 
was almost impossible, and the countenance was depressed and anxious, and 
the skin assumed an unusually earthy aspect. On the evening of the 24th of 
February, the bowels being slow, an enema was ordered for him. Shortly 
after it had been administered he became dreadfully agitated and alarmed at 
the idea that he had made use of the same instrument that had been employed 
for administering injections to Mrs. M., and told his medical attendant that he 
had undoubtedly imbibed some poison from this source.* Being assured that 
this was not the case, he became calmer, and said that a great load had been 
taken off his mind, and that he should now get better, for that his sore throat 

* During this period of anxiety he had severe rigors, and was extremely restless. 



1852.] 



Midwifery. 



267 



was entirely gone, and that he could now swallow without difficulty. In the 
night of the 25th, however, high fever came on ; the respirations were doubled 
in frequency ; the pulse was 140, full, but very compressible ; and the restless- 
ness was greater than ever. lie now said that he felt no pain whatsoever, and 
no longer exhibited any anxiety about his condition, and even expressed sur- 
prise at his being so extremely restless. The fauces were of a livid leaden hue, 
but exhibited no signs of gangrene ; the tongue was furred, and the breath ex- 
tremely foul ; the skin was rather hot ; there was frequent retching and nau- 
sea ; the respiration much hurried; and the peculiar leaden or earthy disco- 
loration of the skin was more strongly marked: there was likewise intense thirst. 
The chest was more carefully examined, but not the slightest abnormal change 
could be detected in the lungs or heart. He had but little cough, and this 
seemed to be chiefly occasioned by a thick, ropy mucus, which was secreted 
about the fauces. On the evening of the 26th, the bowels not having been 
opened all that day, ^iss of castor-oil was given, which produced three liquid 
and somewhat light-coloured stools. From this time Mr. M. became deadly cold : 
the skin was covered with cold perspiration ; the pulse continued at 140 and 
150, bat became gradually smaller and smaller, in spite of all restoratives that 
were used, till it was no longer felt at the wrist, and he sank at 12 A. M. on the 
morning of the 27th of February. 

" About the 20th of March, a sister of Mrs. M., aged 33, who had been in close 
attendance on the invalid, and likewise upon Mrs. B., was attacked with swell- 
ing and pain of the glands of the neck. In two days ofter this a well-marked 
rheumatic affection came on ; the ankles and knees swelled, there were fever 
and intense pain on moving the affected joints, with copious acid perspirations. 
The affection was of the kind termed synovial rheumatism by Dr. Watson, and 
amended after five days' use of lemon juice ; but it was more than a month 
before Mrs. E. was restored to health. 

" One of the nurses, after five days' attendance upon Mrs. M., was in like man- 
ner attacked with swelling and pain in the glands of the neck, followed by a 
complete rheumatic affection, which was both more prolonged and more severe 
than in the case of Mrs. E. 

" A young girl, aet. 18, was engaged to assist the nurses in their arduous task, 
and frequently assisted in changing the linen, and in moving Mrs. M. from one 
bed to another. At that time she had a slight scratch or cut on one finger, 
which, two or three days after she commenced her duties, inflamed, and this 
was attended with low irritative fever. The hand and arm swelled immensely; 
suppuration came on very slowly, but a good deal of pus was evacuated when 
incisions were made. She eventually, after nearly five or six weeks of illness, 
recovered, but was left in a condition of extreme debility. 

" The woman who waited upon this girl for about ten days, was seized a few 
days after going home with erysipelatous inflammation of the throat, with pain 
of the hack and sides of the neck, and with muscular pains over nearly all the 
body ; she had low fever for about ten days ; pulse from 80 to 90 and rather 
weak, and she regained her strength very slowly. 

" The house where this melancholy catalogue of diseases occurred, was a large 
and airy building, situated in an elevated spot. The impression first made 
upon our minds on seeing Mrs. M., and which was also the opinion of her 
usual medical attendant, was that the patient's symptoms arose from purulent 
infection after delivery. The gradual progress of these cases has been well 
described by Puzos, and by Sedillot, nor have they escaped the attention of 
English writers. In many instances, the poison, if we may so call it, tends to 
form deposits of pus in various organs, and particularly in the pelvis near the 
broad ligaments of the uterus, from whence they sometimes point externally 
in the groin, or discharge themselves into some viscera. The case, however^ 
soon ran on into genuine apoplexy ; but it would appear that the poison still 
remained in the system, and infected many of those about the patient. Mrs. 
M.'s case was one of those described by Mr. Travers, and others, and especially 
commented upon by Mr. M. B. Gallwey, in his excellent observations on asthe- 
nic or unhealthy inflammations. In nearly all the patients the afi'ection began 
with pain and swelling of the throat, and then branched off into the various 
forms of erysipelas, erysipelatous sore-throat, and rheumatism. 



268 



Progress of the Medical Sciences. 



[Jan. 



In the month of April, Mrs. M. was attacked with severe pain in the par- 
alyzed thi^h ; the veins were evidently inflamed, and, in fact, the medical 
attendant described it to me as a complete attack of phlegmasia dolens. Was 
this the last effort of the poison which had been circulating in her system?" — 
Lond. Med. Gaz., Oct. 1851. 



MEDICAL JURISPRUDENCE AND TOXICOLOGY. 

42. Case of Poisoning hy Tincture of Aconite. By B. W. McCready, M. D., Pro- 
fessor of Hygiene and Toxicology in the University of the City of New 
York. — [Communicated by Dr. T. R. Beck.] — On the afternoon of Friday, 
Aug. 9th, a healthy Irish woman about 25 years of age, called at my office 
in a state of great alarm and agitation. She brought with her a bottle con- 
taining strong tincture of aconite root, and stated that an hour previously, 
while suffering from pain in her bowels, she had swallowed a tablespoonful 
of the poison, mistaking it for brandy. Her countenance was somewhat 
flushed, though this was probably owing to her having run a short distance ; 
the pupils dilated, though sensible to light ; the pulse frequent, soft, and 
weak, the beat being sometimes so feeble as to be almost imperceptible. She 
complained of a feeling of fulness about her limbs, as if they were about to 
burst, accompanied by a sensation of numbness and pricking over the whole 
surface. There were numbness and tingling of the tongue, and a strange sen- 
sation about the throat. There was no sickness at the stomach, and the head 
was perfectly clear. I gave her an emetic of sulphate of zinc and ipecac, and 
in half an hour called to see her at her house, which was in the immediate 
neighbourhood. She had vomited about a pint of thick fluid, consisting chiefly 
of partially digested food ; but, as the vessel she had used contained other matters, 
I was unable to ascertain the presence of any of the tincture in it. The 
pulse (she was now lying down in bed) was still frequent, 120 and feeble, the 
beats continuing irregular in force. She complained of feeling weak, but in 
other respects was about the same as when